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BUILDING- INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS OWNER BU!LDER DEI,CARATION
<br />I hcrcby 0rfirm und.r pcfulry {,r pcrjury ihdr I m .r.q, nn r rhc Co.tr.rtrl Liccnsc t w lor lhc rallo*ing rcN)n lSLr 70ll 5
<br />B!\in.* and Pi(,fc*ion C{ric) ny Cn, or Coumy whiclr rcquncs I tcrnrir 1,, coosrrucr. alrcr. ihlrovc- d.n{ni\h or tutaii nny
<br />{ru.turc. priorro irs issuamc. aho reqlncs rhc applicanr ior suchIcmir b lilc r signcd dcmm rhar h.or shc is li.cnsed Pursanr
<br />ro rhc F)virions ol rhc Cotrkrcro.r Licctrscd tiw (ch.!rc.9. Commncins $ilh Seclion 7U)0 or Diltirn I orrhc ausinc$. d
<br />Proic$iotrr Codc) or lhrt hco!shc is crcnur thcrcl'rorand Ihc brsis lbr lhcrllcC.dcrc Driotr AnyviohrionoiSccrio!?oll5byan,
<br />appliunr tu a ncrmir slhjc.a rh. ippli.rnr b r.ivilr.nrhyornor nxncrl[n rivc hundrcd dollss (55m)
<br />l.rs owncr.llhcnrorEny-ormyenrDbya\wirhwa!c\rsrhcn!,h.ornp.trsrri.n.willdolh.${nku rhcituurcnni
<br />i' c' .il or ontrcd for et (Sc. 70,1-1, Bu{ircs( Md Prcla$idN Cnlc 1 h. CoDtu.&r\ Liccns liw docs nor lPply k, an o*rcr of
<br />0r pDpcny *Fo huikh or i'rtx(,hl rlrrs . ifrl Bh. dc\ such B)l* hinFcll o, i,cEclf or rhrongh hi\ or hor own cnDhycci
<br />tn'vnhd rhd nrch iryrornrnh c frn inrcndcd or ollc'ln 6r sh lr- howckr. rh( buiidi'i! or in',tuvc rnr is eld sithir om )cir
<br />olconUkrii[ rh Osncr Brildo sillhrv. rlr hofln n orF,vnB rlli h. or sh. di nor btrildor in[mvc lhc pmFnylirrlf purFrv of
<br />l,,sosncr.rrhc 0.pcny. anrcx.lu\ivelyconrn riDr wirh licctrscd.onkmr{ns h.oiiflcr rh. Pu..t (scc. ?(!4. Busm$
<br />rnd l}nrasri,n Cod.:1hc Cont cr.r'r l-i.cnsc l-aw docs nor trmly t' ai.smr ol[or.ny eho huilds.r imlnvcs rhcr.o!.
<br />trid who conrB.rsf(trsuchproj.r*wirhr cbtua.ro(s) lmtrs.d lusu.nrrorhecoorracror's l,iccnsc l,i*)
<br />I a icrc rpr trndcr Sc.ri,n
<br />Dale: Osn$:
<br />\TORKERS' C(IItPFI\SATION
<br />DECLAAAUQN
<br />I hcrcby.,Ilnn uMcr lxtrdltyolFrjuryonc ollhc ri)llo$ins dcclffulionv
<br />-l
<br />tr\t andwill nuinrrin uC.nifi.rrcofConsc i, s.lt li\urc r(tr work$f .on!En\r ion, rs tmrided lor h!sccrt,n]Tmorrh.
<br />Ltrt$r Cod.. ftrlhc pc.lornurccolthr *ol1l tuBhichth. pennil is hsucd.
<br />I hlrcr.d *ill nri rir work.ri conrNfulion i'rsurnrcc. !\ rututoJ h!Sc.iid I7(Xrol rhc lrhor Codc. l'or rhc l}crlomrm. of
<br />lhc qork lu qhichrhhtcnnir i\ isnrd My*ork.s c.nf.n\dt)n instrri.c.n $uMB)licynnD$crtrc
<br />. 17*72 iLD O
<br />I c.niryrh,r ir dr. tf,rlonrwmolrhc snrk Lr whi.hrhi( pcrmil
<br />$ !slo hccom lubjccr hrhe $orkc^ co'np.tr\rrion h*sofCrlinff
<br />workcr con,pcnsrrn,n pn,vi\ion\ ofSccrion l7(D.fihc ljhrr Cdc.
<br />is isstr.d.l \hrll nor Mrrloy nny!csotr ir 0trynrtrner
<br />ir. md.grc l[it ill should bcconf, subjcd brh.
<br />.I rhrll. Ln[trilhcotrlp], sirhlhxc pn]vni(nr
<br />nkwtul. xnd \hrll {rbJ.cr rn cnrloycr r. airnmrrrrrurrics,nd
<br />ri,m t) rhc co( of.o D.ns.riotr. drrugcs os providcd f{n rh.
<br />WARNIN(;: Failxrc k, \ccurc wnk rJ conlEnsrliotr
<br />.ivil fitrc\ up tu onc hundrcd thousrnd tl l{
<br />S(rr{ rlrT6olrlr l.rh{ (,trId. .r.{xtr,lrr l*-:L:t^,.. 1l7u/ t 6
<br />DEqLAiAIIOX
<br />I htrhy trililn ufilc' F.ahyofl.ijnr! rhnr I nn liLrn*d nMcr pmvkion ol Chlrls I (co'ntuncin8 {irh s..thtr 7m0l {fDivkion 3
<br />ol lhc Busincslnd Pmfe$ioosCodc. dnl nry li.cn\c is in lillfd.caMclLtr
<br />(C24tL
<br />CAN$IAJJCUANI! IITNGA{jENCI
<br />lhercnyannruDdcrpcnolryoll).rjlryrhcrrhcrisr.onntu.rinrlctulingrgcnctforthcrerfoinEnccoflhc*orhrorwhtlrrhisF.mi'i\
<br />nnrcd (Scc.:1097. Civ C.).
<br />drfucrNLD[ltaS rlt]!
<br />I hrr$y rtirr und$ ncnalry olncriury o.c oirhc iouo*irs dccliturt'ns:
<br />Dcturlirn,r PcnnirsAsb.(o\ Nolllic i l;cdcra l R+uhr bns ( l irlc 10. I'rn6)
<br />Rcqui'cJ l.rlrcrol Norili.nliL
<br />_l..nily rl, ill rid.rrl rrgrLtr oN rgmlr rE r\trxir rc u rl d c tr.r 0plli.xht r, rhi\ !ft,1$t
<br />oftlirrtr.cs rtrd Shrc Ir$s rclding ldins condflcrn,n- , hc
<br />xho!r nrnr(rnd t,'ot).n! l(tr d:
<br /> lrDlicanl or /1gonl Signnlu(
<br />.frhis Ciryand Counrylo cnro lll)i rhc
<br />'.,:a/sn/utr
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Roof Sheathinq
<br />Framing
<br />lnsulation/Energy
<br />Drywall tl/t//v Ar?o>ra r'zz.-'
<br />Ext./lnt. Lath 1 1o'tl lt 4/ili/i-/fl,
<br />Brown Coat V
<br />l\/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL It /,Ll M /n-
<br />Certilicate of Occupancy
<br />Notes, Remarks, Etc
<br />SITE-WORK
<br />Shear Wall
<br />,,u., n',,*, _21:91L115 b [\pncs
<br />-
<br />4."-, ka
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