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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BU!I,DER DELCAR TION
<br />I hcrby a,ltm unilcrynilly .f i'crjury rhd I m .xcnl,r rro'n rhc A,ntrdon l-iccisc ti* ,n lhc rbllo*in8 rcohn (Scc 7031 s
<br />Busi|css rtrd Ptuf.ssn Codc) iy Cny or Count, which rcqutcs ! ncnnit ro consldct. rlrcr. inrfrovc. dcnnish or ml n any
<br />In,cru(. pri{n lo n\ hsurrcc. also rcquncs $c,ppli.nnr r{, such lrmir h flc r si8md sr em lnat lEor shc h li.cord nuruul
<br />h rhc povisiotr\.rrh Conrrrois Li..n\cd ljw (Chaltcr 9. ComnrcmirS wilh Sccrio Tofi).f Division I ofrhc aurrcqs and
<br />Pmtcssions Codc)orrh,r h.orshc acxc rprrh.rtio'nlld rhct{sis lor lhcallcsedcxcmprion. AtryvnndionofSc.lion701t.5byiny
<br />aFili.rnrt,apcnnirsuhjcclslhc.mlicanllorcivilp. rlrlninoi nxrc rhrn ll!c hu rcddoU!n(55lX))
<br />-1.
<br />!\ owrcrolrh. lroFdy. (n nrt cnuhyos wirh wrsc\ a\ rhct slc compctrlxrion. will &' rhc rut aM rhc (nrlurc h ml
<br />irrcnddl drollcrcd Lr qlc lS(7()tt.lluin.ssrtr ProL$ion\ c(ic Th. Co tDckr'! Lr.nsc Lnw d{'c\ orarpl,t,rnosn$of
<br />rhc pm,f,ny *hohtrildsoriDpr.!c(rh.to.tr,ddwhod(f,ssu.hw.rkhin\cllorhcrs.llorrhroushIisorhcro*ncmnlorNs.
<br />ll(ivi,l. rhrr nkh impmvcftnrs m nor inrcndd .r ot rld nn srb ll hoNcrtr. rhc hurklill3 or i'npmr.nr i\\rLtsiihtr'I{! )r.tr
<br />ofconll)lction, rhc Osncr Buikld! sill hrvc rhc hurdcn ol Dnvirl rlurlrordr dxl or huild or iron,rc rhc pmpcny nnrhrJlur|rNcof
<br />Ln\.wicrolrhcpmFny.rncr.hKiElycotrridi,r!n,thli.cn\cdcoftndtr\!,.oinrudihcpmjc.r(sc.7ol-1.Buidr*
<br />rnd tlnnshn Corlc ThcC:onlru.r.fsLi.cn\dl-rw(l,EsnoirptlyroM wncroipr)p.nyqho hnildsot inrprnrs ihcrcotr.
<br />rnd who .otrrBcr\firsuchpmF(*irhtrco ncro.lsilmn{dDU^ur[r,rh.cin r..rtr { l-i&n{ tjw )
<br />I flcrrn,tr r or Socrn'
<br />Dole: O*ner:
<br />lV{ rr.KriRv c(lNtPEiisATroN
<br />D.EI;LAIAIIOB
<br />I hcrchy.flnrn utrdn lrhhyofl[iuryoN ofrhc rblbwine cclrrdions:
<br />I halc ald qill.minruin. C.niatr c ol Clnr*nr b Sclrlnrurc fu workm .omFn\al ion- $ providcd lor hySc.rion.r?m ofthc
<br />lihor Codc, lor tlr !.nnmakc .l rhc work rd shict rhc p.rmir n issucd
<br />rhc \r.rk f.r shth rhn pc.mir i\ i\sufrl MyIorkc mnltl. \rriu in$fumc.ffiicr,, trlirynunhu uc:
<br />t\ri.y Nunhcr_
<br />-l
<br />ccnilylhd ir rh. Nrrormnc..rrhc work fttr which rhi\ ncrnril n tucd. I shall nor cnrploy.n, p.ron i. any nunncr
<br />$ $ k, hc.6m suhjcd k, rhc sort.6 comn nsrtion lrqs.fCrlifonrir. md l!tuc rh{ ifl should bc.otu srhj.rr k, rlf,
<br />work.r'.lnnFnsurirnrnviltlnsofSccrionlT{Dofrh.tihtrCdl.,lsturll.lonhsirh..nrllysirhrhorpft,li\iont.
<br />WARNING: Faihm ro $.urc work.^ L\nnFnsnrion .ovctusc is unhwtul. rnd snrll suni.t r!' cmrloycr ki si'ninil tcnrltics rnd
<br />lill,11"il,',LiHT,I::"{:li::}.ll
<br />,."' c///tr
<br />I ltrrthyrllnn,rDdcrpcnrlryol t{rjury(hal I Jnll undcr pmvhion olChitlrci 9(commncnrE wirh Sccrhn ?uD) oIDilhion I
<br />,'l rh.lll\i,,.\\ rnl fiiilcr\i,trr\C.rLe. rD(l ur- ]r.tr\c ^ i'r tullturcc ctr..r
<br />-
<br />Ihcrcby!firnr undcr lcmhyoipcrjury rh th.rcka.oNflcrn,nkndirgr[cnctrttrrhcFrturrntr'rc.rrhcworkr.rwhi.hrhislf,nniri!
<br />i(sucdls( l097.civ c )
<br />AITUCAILDEILAE{II!]N
<br />I ffiyrmnnundcr lcna,ty ol lrrjury.nc orrh. rolbwins dml{ ioos:
<br />Dcmolirio. P.n r\ \h.{or N.r i.!in'n FcdcBl Rcsulationr lTn[.10- t'!n6t
<br />-Rcquircd
<br />tJrl.r of Norifi .ili
<br />lr.nilyrhrrrlr,id.rrlr.gtrhri,,n\rc!rklintrdr(rr,\(aD\nlr.Ninfflnrhlcr,rh\t)i.tcLr
<br />Ilcdir\ lhrr Ih .nrlrhr.tr )li.rri(,ri,xl{ircrhrrih.xhivclnli,iinrri, i\.on..r I rsrN ro.omply sirh nllCirr,nr Counly
<br />onliNtr..\ Md Srnrr l-aN\ dllriryt, bui nt(on{
<br />.lxrc rr rr,'d p'o|.'1y1,tr i'nnrril),
<br />ADIlicn l or ]\lrnl Si[nxlur.
<br />Prrn rN n.nn (trnrll:
<br />yand Coudy lo cnrcr uF)n rhe
<br />6, )" *
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVl nsulation
<br />Shear Wall
<br />Framing
<br />lnsulation/Ener
<br />Ext./lnt. Lath
<br />Brown Coat
<br />l\,4aso n ry
<br />Pool Fence
<br />T-Bar
<br />Flood Zone Certif
<br />FINAL b 4Z-re J/,zC .A.Ge)
<br />Certif icate o! Occupancy
<br />Notes Remarks Etc
<br />Erection Pads
<br />Roof Sheathinq
<br />Drywall
<br />Handicap Beq.
<br />Deputy Final Report
<br />Enqineer Final Reoort
<br />LcMcil Addr$
<br />I
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