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BUILDING- INSPECTOR RECOHD
<br />DATE ID/SIG.OWNER BUILDEi' DI]LCAR4TION
<br />I hcnby nlrtnr un.lcr p.mlry (,rNrjurt rh lmcrcnpl rio rhc Cotrrrrkm Li(cn{ Lrw lff rhc iollo*in! rcr!,r l sc. 70:11 5
<br />Busi',cs\ rnd Prufcsst,n Codo: Atry Ciry or Counry *hich rrqutc\ D Fnnil lo mNrru.r. illcr- nnPnJvc, dcmolish or rcI\'t lny
<br />{flctrtrc. Drior lo irs Gsurncc. ako rcqrires rhc lpPlicrtrr frtr su.h |tirnit lo ljlc i \i8trrd nd.Im r rhar hcorshe is lic.Ncd p n mr
<br />t,lhc r{,li\tuns or rltr Conrrrclois LicNcd l-rw (Chapi.r 9. Connncrcins wrh Scdion 7(xxr of Divntutr ] ol'hc Bu\incs rtrd
<br />Pn,fcssiotrsOnlc)orrllnllLor\hri\cxcmnrrhdr.fnnnr rhchrrllorlhclllcs.dcremprnJ. Atryvnrrir)noISccriotTIr:ll5hvMy
<br />,pplicatrrturrp.rn,ir\dbrl.Brhc iptlicanr ra !civill..alryolnor ft,crhrtr I{c lrundrcdd.ll \(S5(X})
<br />I. $ owncr olthc f'opcnr. or fiyr'nplotccs snh w4cs N rhctr Elc $mPc.sdnnr. silldo rhc wod( and rh. sl lmimr
<br />inrcndcd oror1crn for sh (Se ?(x4. Buircsrnd PrelcssionsGxl.: TlrConrrctois Li.enc lrsdoesfr lPPlyto!no*ncrol
<br />rhcpmlrn, who huilds or inlprovcs rhcdn. dd who d(s su.h *od( himsclfor hcrcllor rh^nrgh his.t hcr own cmplo!.*.
<br />pn*iJcd rhrt $ch i'n!turc.f,nh rrc not i c.dcd oroftcrcd lor$h.ll hoschr. rhc h{ildin8 or iDpmrtmnl is \okl wiihinnnc )c
<br />olon{krion- rhe Owncr Buiu.r qill hrlc rtE budcn ol|rovin8 rh0t hc or sh. did frn hdih or irlrovc th. pmldy lor rtr N$,eof
<br />-l-
<br />ns oNncr or rhc l,r(Ddy. nm cxclusirc ly contr(tins *ilh licn{d conh.hn ro $nslrucr rtE nrcF.r (s.. 7()'l4. Bu\irr.r
<br />Md Ptracssirtr Codc: Thc Conracttr \ I-iccn\. L,u docs n.r attly to $owncr orpmr.dy wh. huilG or imProv.s rhcrcotr.
<br />rnd who.otrtrcrsrorsuchproj(l(wirha('ont$rons)licctr\cdrursurtrtrorhcGfinrtn\l-iccnscl-rw)
<br />I nn.r.mnr undcr sNtron -8.&PC lor'hi!rc!'o.
<br />D.r.: OFnc.:
<br />w()RKt_I{S', C(,\tPtit\sAl IoN
<br />DIgLA&I]IAX
<br />I hcrcby rltun utrdcr pcnllryolltrrjury oic.fr[c nn[)qirE dcclarrrions:
<br />lhrvc rlwrllnui .in a Ccnificrrcofco.s.nr k, Sclf-I.\urc li{ so cri onrlrisnn.f. as fmvidcd l(,r hy Sdr i(n l7(X) of rlE
<br />lrhn ('ixtc. fdrhcr.llnnMncc ol'lhc work in *hich rhc rcrnr n Nucd
<br />-lh3!cindwillnrainrainaork.N.olxtrsrrioninium..c.arrcquircdhtSc.ri'nr:17($ollhcLjl,orCodc.f(rrhcJ}crlomurcotlhc I'ork lb. whi.h lhn pci,nii is i\sucd. My w.rkcr' comFnsol ion in\oranc.. rin md nolicy nuDhcr arcl
<br />'s? kfO f,tr rn t-t-lq* )"lc (. 1z
<br />I ccdifvrhrr in rh.lcrr.mrn.col lh. sort li,r *hichrhis ncrnir ir isnEd. | \hrllnorcnDl(,!any lcNor in rtrynunncr
<br />\i r(r) hc.otrr suhjccr t, rhc $.rkc^ .o rpctrsdiotr lrqsoiCtrlilhrnii. md a8toc rhdr irl \lnnrld tr.dm sbrccr r.rtE
<br />Norkcr conrp.nsnri{nr nmvi\i('is ofsr.rion l7u).lrhc lnhor Codc.l shnl. f.nhsith.onrly Rirh rlx,{ ntuvnnns
<br />WARNINC: F'rilurc k, r.uto sorkcra conrpcnsnlion cokrsc i\ lihwful. .nd n ll rur'irr ri . doycr ro rimiml ,cnrlriL\ aid
<br />.iril 6trc\ rp t, otrc hondrd rhoos{nd dolloF (11(N).0(x)). in rJdiri,,n k, rlr. c.( ol co l'cn(arnnr. drtrrgcs as provided ttr rhc
<br />Sc!rud:l(,7.o1rliL l^ft)r Lndc. icrc{ r'di .rrcr'
<br />,,.,", . 1lz"(rj n*,n*,,
<br />DEslrrxalto!
<br />I h.mby aliirn uMcr pcnolry ol0crjlry rh{r I am lttn{rr und.r rovisiorolChlPrcr 9 (c.mmNins wirh Sccrbo 7000) nrDivi\i.n l
<br />of rhc Bd\incs and Pbr.ssiodsCodc. ud nrylicc.r is in tull lqcc toxl.ficcr
<br />.t)38 12Ll eo
<br />t-t7 - I c.."*,*,)ld+-"1
<br />CONSTNTI(:]'I{tN I ENDIN(; GI'N(IY
<br />Ihcrchyrnnmunderpcnllryofpcrjuryrha!rhcris,.onslrudionlctrdingrBcncynrrhcPcnirn.trccolrhcw.rkrorwhichrhisFrmilis
<br />i\\ucd (Scc l097.Crv. C )
<br />lrndcis ddr.\\:
<br />-
<br />A.PILLCANLDLEI.dXAIION
<br />I hd.t y dlimDnd$ pcnslry of pcrjur! orc ofihc n,ll,*ing dc.lrr hns:
<br />Dcmolirifl fl Pcr.rirl Asrrsos Norifi.aliotr Fcdcml RcBulnrion\ (Tirh.r0, Pd6)
<br />_llcquted lr(cr of Norill.dion
<br />l.oflyrhrr rl[ l.Jcrrl rc!u]rri,)tr\ rqlrlnr! r\ltno\lctrnrrlr'. n.r r|)I)lic l,lc ri rh: |x,lccr
<br />Iccnllyrh !hNcrc lrhi\ntpli.,rio olxl s.rc lhll rhc .nolc infinnurhn i\.orNL I .8te k, co.,Jny wnh tll (ity rnd Coutrr,
<br />ordir.nccs and Srarc b*srclnrinsro building c.niru(rirr r l l[rcbytrurho.iTc rcfr.sctrlari\cs oflhh Cily antl Cornry k) cnrs u|mnrhc
<br />o^," c 1 1>a'le1
<br />atx,vc rNnnd ptulcn, tu nrsIr.ri,)n furEA:!
<br />^ppric,nror
<br />Axenr si*uruR rX. -t1'r*'1
<br />,"-u**^",nn",,, 7 1EP-EY
<br />l:::-r-<f- t4/k4fA*t)4
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Rool Sheathinq
<br />Framinq
<br />ln su latio n/E ne rqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ir/lasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Ceftif
<br />^_-.\
<br />FINAL *-2-/g J/tJar,{vr )
<br />Certilicate of Occupancy
<br />Notes, Remarks, Etc.
<br />SITE-WOHK COMMENTS
<br />Shear Wall
<br />B:B
<br />f.4f<
<br />I
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