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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNEN BUILDER DULC R{TION
<br />I hcr.by allnn nodcr,cnrlr, ot perjory rhur I u cicmlr trorn rhc C{,nrrdcroF Licc.\e tis lor rhc iollo{ins rca$n (ft.70:ll5
<br />Busincss .nd Prolcssion Codcl: Ary Ciry .r C.x.ry which 'cquids r I.rnir b co.nd.r. alrfi. imrrov.. dcrmlish or mF Jny
<br />(ruclurc, r trlo ils ksuana,oho rcquircs lhc lrtliianr lor suc[ trflnil ro iilc s sisncd st{tcmnt lhal heor \hc i\ licenrd puFu,Dl
<br />ro rM li.visio { df rl{ C.nrncror's Li..[rdd llw (ChaIrcr 9. O)nfun.i.g wnh Sc.rion 7000 of D,!hio. ] ofrhc Busircs and
<br />Pmlcsions Codc) o. thll heorshc is.xcmrr lh.r.fr.n.nd rh. h.sis ror rhcallcg.dcrcmprion Anyviol.rionofScctio"T0Sl5l'yany
<br />applica ror ap€,nir sul'Jeca rhc !ru,licllr lo!civilpcnrlllofnor nmrclhan nlc hundrcddollrr (5500)
<br />L as osncr of rhc F,IEny. or m, enuk yecs wil I wigcs as rhcn sk (mpcneriotr. will do rhr *ork utl rh. n rurc s nor
<br />irlcMlcd oroflarcd for ek (SN.]()44, Ausirlc\s.rd P:.iJfcs\n,ns Codc Thc Cl rr.rof s l-i.cns tjq docs nor al)Plr ro rtr otr rcr of
<br />rhc nmIcny $ho builds or inltr(,ks rhern. ud who d@s \!ch $orfi hinNcll.r hcrcltor ihroush hk or hcr own cmtloyer\.
<br />l)l)vidc,l r har \u.h im0$rmm m mr inrclldsl n oficrud lor $k ll howcrai rhL tuildinS or imprclrftnr i nril wirhi,r onc ytr
<br />ofcon{,lcrb.. rhcOen$ Buiki.r will hrvc thc burdc ol jrovinE rh"r h. or shc did nor tuild or impro\c rhc ptutdy for rh. rxin* uf
<br />l. Jso*ncroirhc prcpcny. mrcrclNivclyc.nhcriDg trirh lrcnrdco tu.hFhcoNn,crrh( I)rqccriscc.7lllj. Bu{trcss
<br />rtrd lhiaxli G c: Thc Co&d(ktr \ Lic.i\c Lrq doc\ nor rnr l) r) M osfcr ol pruNnt $ h,) huildr or nllpn, rcs rhcr.. .
<br />rtul wlr co rcr\|nrstrchpn,r.cll*irh aContrck(t li..nscd N^urtrr n,rh.(lnrrcntr \ l-lccn\.1-rsr
<br />-l
<br />{m ercnrpt !od( Sdion-. B & P C. for rhh rcason
<br />D.lc: O*n.r
<br />.ldoatrEBILlolIIINSATQN
<br />DECITIBdIll]d
<br />I hcrchy 0fltmundcr pcn tyofFrjur, one ofrhc hlli'wir8 dc.luarion(:
<br />-l
<br />harcandwill DEi air r Ccnific.lc ofCo.scnl k' sclf.l.srrc ror *orkcrs cotrDcn$tion. as pmvidcd rbrbySecrn'n l70Oor'rh.
<br />Lihor Codc. lor
<br />'hc
<br />p$fornDo.c ofthc rorl ror whi.h th. pd.rir is isxcd.
<br />My $orkcr' $np.nsrion insurlnc.ladcr and poltynunft.rrc
<br />t,
<br />9ilr$wco(3140 l. t. I(.
<br />.ivil li.cs up ro om hx kd rh.uwd dollus ($100,(XX), in ddirion b rM .o{ of comF
<br />D,r:LLll TdTolE:;;
<br />I hcEby illtrn uMcr Fndlyofp.ryury rlrdr I rD li.ctrwl rr.\r!i( of('h(no 9 (i{nnNr.tr,x rvih S..ri)n 7(xxr).r l)nni0,l
<br />of rhc Busi,rcsmd Pnna\si.rsCodc. dnl ryli.ctrrc i\ i'r tulll.r.. MdclfL.r
<br />fr
<br />-Liens.
<br />Numb€r \q:tuqgn-,;lgs-lt'?o.tt/,{'"
<br />g!.}II.$,IA!CUAIi.LEJDINCIjiENI]I
<br />I hcrcby,filnnundcr Fnahy or p.rjuiy rhar rhcrc i{ r co.sfl.ri,n l$din! necD.y i{tr lhc pcrlonmtrcc oithc work for which rhn pcnnir is
<br />isslcd (sfc 1097.Civ C )
<br />APILICANI.DECLAAAUO!
<br />I h.r.r,y rnim undcr pcnllry ol perjory one of rhc lollowins dcc luari6ns:
<br />Dcmlirion Pclmits' Asbc stos Nor ificor io n lcdcrulRqul ions (Tirlc 4.0- Pan6)
<br />-Rcq!tcd
<br />l,xs of Norilicari,n
<br />I Lcnrry,htr, rh. r.d.rdl r.CUld'.n\ rerdrS a!tr{n\ r.movrl* n.{ +dEablc ro rhh fmrcr
<br />G(:l *n,b rhd I hdrc rcad rh,\apfh!ori,,nondior( rhJ hc,trv. inr{nnorion ircorsr.I aarErocoq)lyw hsllcnyandcounry
<br />ordinrrccs ond Sratc l-aws rchrin8 Io buildin8 consrrucrnr ad rcprc\cnrdivcs ofrhk ciry md counrt t, crrcr ulr,n rh(
<br />$orc mrlnnrcd polrdy tui iDsrNrion purposcs.
<br />ApDliotri or ,\,l$l Si*n lun t>4dt6.'rrrr :1 zr 6 lrl
<br />,^,,,] ] i
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Boof Sheathing
<br />Shear Wall
<br />Framin s lfl,>/t >\36
<br />lnsulation/Energy
<br />Drywall
<br />Exl./lnt. Lath
<br />Brown Coat
<br />l\4ason ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Lngineer Final Report
<br />Flood Zone Certif .
<br />FINAL ( /lo/rs tuba
<br />Certificate of Occu pancy
<br />Notes , Remarks, Etc.
<br />l.eniryrhrr in rhc FrtornEnccofihc aorl ror whichrhh |E rnir is i\\ucd.l shall nor cnrpk,ran, pc6oi in rtrytrurmr
<br />s)isbtrconr\xhl..rhrhcworkcrl.on\F.{nnrh*\ofcrlifdnir,rrdrt(crhmifls,rruldh.conrsuhjccrlolh.
<br />aorkcir conlrnsirion t'iornion\ ofSc.rion l?OOorrh. Lihtr C'.dc.l \hrll.linhwirh.onl['ly wiri rtnE I'rulisi(nrW RNING Frilur. t, korc aork r\'.onD.nsrrnr covcngr i\ unlasful. xnd shnll subj.cr rn cnDloycr ro diminrl,urllic\ rtrd
<br />Ir-
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