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BUILDING. INSPECTOR BECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS oWNER B(III-DI'R DI]LCARATION
<br />I hcrchy rtfirn u .r Fnrhy ,,r pdrjury lh l Mr cxcmrr ftuD rhc colltrNon l-iccnsc li* tur rh. r.l).win8 rcasn (Scc.70ll.5
<br />Bu\nr\\ r Pnrcssion O,lc) Any Ciry or Counry which rcqut \ r Ilcrmir k, or{tu.r, axcr, nn|,o!c. demlirh or Eplt 3ny
<br />$ru.Iurc. piorlo ils hsuancc.nkolcquteslhctrpplicanli,,\!chrcrinirronbanSncd$jtnEnrrh.rhcor+ctliccnsc.lNrsuatrr
<br />t, rh. tmvni.n\ of rhc Conta.r.ls Li.ctrscn bw (Chsrrcr 9. (tnrmcncing *irh Sccrnm lfitr of Divnion I ol rhc ausinc$ and
<br />ProLsionsCodc) orlhar hcor\hc isqcnlrr Ihcrcfronud rhc basi\ in rhcnllc8cd.rcnulotr AnyviolalionolSc.rhnT0.ll 5hyrny
<br />rl]plic!trriurllennirslbjc.hrhcappli.dtrrrciviltcnlry.ltror.rorcrhlnlivchuDdrcddollaB(t5())
<br />-1.n\owmrollhcpnlf,.ly-ormycmpbrtc\slihwrlcs$rltr
<br />n c .urpcns0r ion. will do lhe work !d rhc ntulm L\ nur
<br />inrc' cJ.roff.rcdforsh(SNT04l.Ausincs0MPmfcssionsC{}d€'rhcContmroisLiccnscLowdocsnorapPlyban.wi.rof
<br />rhc F.pcd, (ho hoild\ or iqrdvB rh.En. iril *tu des nKh m* htnsclfor hcMlf .r rhmu8h his or hcr owtr emtlorccs,
<br />|iuvidcd thrl such nnpmlcnrnt\ m ml inrcndql r oftFl f{n !h lf, howdcr, ttE huillio3 or irymtrmnr i\ v'U snhin .nc ,td
<br />of conDbri{nl rhc Owncr BriU.r will h,vc llf hoftlcn or pmvi g ilan hc or shc did mr huitl or iq,ov. rh. F,Fny ior r}r lluqD* of
<br />l.sso*ndrofrhrnmp.ny.a cr.lusivcly.otrhr.rinB wirh Ircnscd conrradon ro connrud rlt InJjccr (SN 71}14, Busirrc.s
<br />r Lhf!*chnCodc: l hc Conrrucxn s l-iccnsc l-!* docs nor apply b nnown.i orFopc y who l,uilds or impnnts rhcrcon.
<br />and who cunra.rs ror \uh proi.ts wirh. conrBtuns) liccnsc{ Dunur n',hc G,nrrrcroi\ Li.cn{ ta*)
<br />Z" lZ
<br />I hcrchy !llirm trnd.r pcnxl!y oln.tury om olr[c n)]k)ai',! d.(lrrrri(rr\
<br />I hnvc,rkl*ill nEir airrCcnra(trrcofConscnltoScli.lnsurclor$orkcr'c.nDcnsdioi.A provi'lcd lor bySdion 3?fiJ ollhc
<br />Lalnr C.xlc. ltr r hc F f.flMn.c oi rhc wo.* for Nhich rhc p.mil n issucd.
<br />I hrvc lnn willnri rir sorkcs compensrri{,D insoraE_c. &s rcqrncd bys(rnrn:lTtDolrhc l-lhorCodc.lbrrhc Pc'fodin.c of
<br />rhc work l'or *li.h lhirpciinil is is$cd My wolkcr'(,nrp.tr\,rnrn nr(urai.c.rricr and !olicy nunhcr rc:
<br />P.,la r t\u'ih
<br />-f
<br />\ric.
<br />l.cnifyrhrr nitu pcr,nnMoce.irhe*olk lor $hi.hrhi\t ilnir i\ isntd.I n[l]norc lt,.ydtryNrsotr ir any nunmt
<br />$ $b hconc \uhjcd h rh. *.rkcricomprn\nri( ldw!olcdliturii{ rM ag(..c rhrlil I \htr,ld hcqn* \ubtd orhc
<br />wo*crs compcnlarimpnrkt,n\ofSccrtnrl7(Dolrli.IrhtrCr..Islmll.,ndh*irhinnplt*irhrl{xcpmli\iod\
<br />WARNIN(; Frildrc t) {.!rc sorlch .otrrpcrsrrior.ovcr !c is utrlrrii,l. rDd ll \!hjr.r M c'nploycr ro cimirul I'.Mllics ond
<br />ofcompcns"ri(,n,lrnn'!.s rs trovid.d tur lhccivil finc\ ut b on. htrndr.d rh.trsrirl dollrs (Sl(X
<br />(
<br />t il,,( 1,\lt\ll()N
<br />Ihcruby116r unddr p.ndlryof,rrlury rhJl I om licctrr{ undct tovi\ion
<br />ol lhc Busircs lnd ftorcsion\Codc. aM nyiic.trsc h ir tull lirr.c ond
<br />rrtr l.onnrf, rtrrs $irlr S..1Dtr TlrroL ol I)nisi,r l
<br />Liccnsc Cllsr-Liansc Noml,€r:
<br />D.l.: Contmclor:
<br />CINiIBIIEII!]NIINDIIC.AGIIIjI
<br />I hc(b, notd und.r Fnallyofpcrjury thol rhcrc h 0 cotrstrucltin kndins lscncy for rnc !.rfortun.. orrhc wor* Lr whi.h thir lErnil is
<br />hsucd ( ss. 1097. ci!. c )
<br />AITUCANLDECI.AEAIII]N
<br />I hdtny altim undcr Fnaliy of pcrjury orc ol rhc follovi.E dalarrr ionsl
<br />DcnDlirion Pcrnir\ A\bcstx Norifi.rrio. F.dcrrl R.guhrnns (Tnh40, Pan6)
<br />R.qun d Lcnfi of Norificarion
<br />I.cd'ryih,r lhrvc rcdd rhisaDDli{lirn d (alclhnr rhcltDvc inlntrHlim h.orc.r LlrelocomPlrwirhallCiryandCoonr,
<br />oftlinamcs rNl Srrlc tjws rhrin8 ro rurhori7c rcprc\cnrrinc\ .frhis City ud Counly h cnr.r uI)nrk'
<br />xh.Y. nrnrntrr.d fn)N,rr lor
<br />^*--efqfsug,lppli(nnl or Allcnl SiaBl n
<br />d AXidt;-
<br />t].
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Flool Sheathing
<br />Framino
<br />lnsulation/Eneroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />l\/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Depuly Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />I
<br />toltl lt*irir..r..,<nre u\t
<br />Certilicate of Occupancy I {fJ
<br />Notgs, Bemarhs, Etc
<br />Erection Pads
<br />Shear Wall
<br />FINAL
<br />L.h,lcr s Na'E
<br />-
<br />knCci\ AddE$
<br />-l
<br />ccnily rhur rhc ltdsaldsuLrn,n\ rcSddine asb.sos rcnrrvrllrc nol oppliclhlc ro rhi\ !n,jccr.
<br />?P
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