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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE tD/stG.COMMENTS OWNEII BUILDER Dl]LCARATION
<br />I hcEhy 0lfiirn und.r trn y or p.rjury rhdr I m cicnpr ln'n lhc Conhcrrn Liccns Llw for thc lollowing rcdsn (Scc 7031 5
<br />B!\incs and Prclcssbn Codcl Any ciry or cou.ry which rcquircs a pcrnir ro onnrucl. altq. inrDrove- dcmli\h ct EIon any
<br />{ .rur. pri.rro ils n !ncc. aho rcquncs lhcapFlk.nr ror suchFmir ro fihaikn.d ndcrm rh,t h. or lhc is li..nscd pr{ar'
<br />h rhc rrolnios ol rhc G,nrri.rois Liccn*d L,w (Chllrcr 9. Comn'crcins wirh Sc.rion 7(xxr ol Division u ot rh. Busilcs r.d
<br />Pi,rtc\si(nrs Gnlc) or rhat hc or shc is ercnpr lhcrcfiom dlhchrnrforrhc ll.gcdcxc lption. Anyvi.lbrionofS..ri.tr7011.5bydn,
<br />rp,'licrdri".tlcrmir(ubi..krh.rptli.rnrkacivilpcnalryolnotnnircrhmfivchun<l.cddoll0n(Sslxj).
<br />I.$osnrolrhcpropcny.ornrrcnrpk,yccswilhsagcsr(Ihcnvr..omp(nsil,..willdorhcwDrkaidrh.{turmhnor
<br />inrcMcd or.flircd for {1. (Sc.70{:t, Busin.s lnd Pn)lc$ions Codcr lhc Contr.ctois Liccnsc Lrw do.s.orapply io an owicrof
<br />th. ImDcny sho t&ildsor irprorc\ rhcNn..nl wtx, dfts rrch Mlt nntrsclror hcrrllor itrcush his or hcr own cmplDcus,
<br />pmvidcd rtu( such imptuvurrunh m nor inr.tulcd or onimd lor eh ll lDecvcr rh. t{ildir8 or inlpmknEnr is $H wirhin oic Jrr
<br />olcomphli(r ihc Oqncr Build.r will tnvc rh. honlci ol'pmvilrg tlur hc or \hc dil tror huik] or iryx)R rhc po!.n, fd rh. nulfx)*of
<br />L rsowtrc'ol rhc pmPcny. !ncrclurivelyconirktiDg wirh li.cn$d.o rn.rnsb cotr{tucr rll In,Jcrr (SL! 7t!1. Buw.\
<br />rtul l,Jllcssir Cudc: Thc Conra.t(r'\ I-iccnsc l.aw dtrs notrtplyro 0nowncroltropcrlrwho btrilds or improvcs rhcrco[
<br />8trd *ho conhcrs tu such poj.rls wirh a o,nra.fti, lkctrfd puFunr b rhc conrladn s l,iccn{ tjw).
<br />-lrDcr.Nt
<br />undcrscdtr .B &PC lnrrhi\rm{)n
<br />Dor.: Owrcr
<br />WORXI.es C1|NIPFNSATL)
<br />DEIIAXAIIAN
<br />I h.r.by rflirm undcr ri.mlryofpcrllryore olrh.lollowinx dekr.rt,nl
<br />Ih!rcudwillrui ii,r n Ccnificalc ol Cotrsnr ro Sclf-lisurc tur qorkcrs ..df,cnsriioi. is pruvidcd itr l,y 56.'rion.l7 )olihc
<br />Lf,tx, ('qlc. fitr rhc Frfoirun.c ol rhc work ror whichrhc pcrdir k is\uc
<br />lh.yc,kl will rinrrin korkcrs' conD.nsari,'n inrurorEc. o\ rcquird ny Scd im 171D ol thc tjhor Codc, hr lhc pcrlnnmmc ol
<br />lhc $1trk r(tr shichrhi\ pernir is isu.rl M, workcr' oaDctrs.l rtr nNurmccmricr rnpolicynumbcruc:
<br />-l.crriiylhnrhrlrErfonntrtrccoirhcBorklorwhi.hihi\p.nniriris
<br />rJ. I s)x'll nor .nfl,), any pcrkrn in "iy !n ncr
<br />$ N k, b.co'ft srbjsr h rtc sori.6 coopcn$rion laws.lC0lirornir. .nd lge rhd ifl should bcconE subjcr r. rhc
<br />sork$\' .onFnration P8)!n&,ns of sccrion l7(D ol rhc l-atry On,c. I sttrll. fonhwirh cotr{'ly s irh rhoE pmvtnns.
<br />WARNINC: trailurc to su.c so.kcN ompcnsirtotr.ovcn8. is xtrh$ful, and drll \ubr..r tn cmplolu ro c m,nallxnilric\ ond
<br />civil fincs un lo otrc hundrcd lhousrnd dolfun (SloO.Ur). ir lddirhn r. rh. ro( ol.o'npcNarion, dd idgcs rs provid.d for rh.
<br />sccrion 1076 olrhc LltDr Conc. inrcrcnanddtorrcr's rNs
<br />Dar.: Appll@nl:
<br />r r.FNsrp cdNTR crft)R
<br />p&qLA8dIoB
<br />I hcEby alfirnxndml).nalryorp.rjury ih,r I am li.ci<! urdq rrevtion ofChaprs 9(.omftmins wirh Serion ?0lo) orDivi\n n l
<br />of lhc Busirc$ and Pol€ssions Codc. aDd my liccnE is lirll lore {ld cfltcl.
<br />IANSIA]JSUQNIENDIXCJG};NII
<br />I hcrchyn,llrDuMcr Jf,nalr!ol p.rjuryrhrr rhdc issconrrtucri{,n k iryaE.ncyforrhcp.rronuiccolrh.*orkturshichrhNlxhnnis
<br />i\sucdlscc :r(y]7,civ c )
<br />L.ndcls Addrcss:
<br />-
<br />AITLICANfDEIIAEAIIQN
<br />ItrRhtslinnuftlcrI. lryof trrjury,'ncolrlIl'olhsirsdccl&ri,'is
<br />DcnFllri.n Pcnnils Ashcsror Noliricarion lt cralRcsul mns (lirlc.r0. Prn6)
<br />Rrqui'rd lrrr.rol Norific ion
<br />-lccnily
<br />rhar I hlvc lcad rht lpdicarion and norcrhllrlrdnvc i nnnllrtr k cotrccr I r8relo.onrDlyairhall
<br />onli,In..s intl strrc t,nsi rchli,rg ,"'wu**.,r-
<br />nhove mnri()ncd pmpcdy hr
<br />y LL H-e <-t
<br />4L"1
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenUlnsu lation
<br />Rool Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Ene rgy
<br />Dr ywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />t
<br />FINAL /rlr&h"^\/ACertif icate ol Occu anc
<br />Notes , Remarks, Etc
<br />Set Backs
<br />Poltr v\un'tfl _l.xnrc{
<br />t ndcarlr!tu'_
<br />I(cniltrh rlr tudddrcgul i.tr\ rc8nftlitrB r\h.nosrcNrrlrrc mr{tlic tubrhistn,l.cr
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