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BUILDING. INSPECTOR RECORD
<br />COMMENTSSITE-WORK DATE ID/SIG.OWNER AUILDER DDLCARATION
<br />I hcrchy affirnr undcr rdn0h, ol pcrFry rhd I m cicnrpt frcr rhc A,nrrncbd Li.cd\c tjw tir rhc f.lhwirB na$n (Se.7lrl.5
<br />Brsiic* a.rl Polcs\i.n Codc): Any Ciry or C.uniy which rcqutc\ a pcnnir b onnru.r, rlicr. inlprulc, &mlkh o, rcp.t any
<br />sfl.turc, l,Drro ns hsu,nc. also rcqrncs thc rpDli.ant for slch lErmn to filcasistrcd sralcmnl rhlr tc.rshc i! ticensed rur*lni
<br />b rhc pruvtn,ns or rlt Co.k{.tr's Li.cn\cd tjw (Chrpr$ 9. CinmcRnr8 wirh sccrio. ?000 oi Divhim I or rhe lrusnrsr $d
<br />Pmfcssiotrs Codc) or thr! h. or sh. is cxcnpt lhcEt'ron otrd Ihc brsh for lhc allcecd crcnurion. Anyliol,rionoisc.ri.n 70-r 1.5 by,trt
<br />dtplic{nl for n p.nnil subjccklhc applic.nt lo rciviltenrllyofnol nmre lhan fivc hhdEd dolla^ ($500)
<br />l, n\ osncrofrhc fmNny. or nrycmployccs rith sr8.s ns rhcn sh.orntcnsorion. willdo lhc w{nk ud rhc nmh n nur
<br />i cndftl or oltircd lor srlc (S( 701,1. Busincs and hofcsinl Codc Thc Coitrcttr's Liccn{ liw do.s tror rppl! k, nno*Mr.,
<br />rlrcF)pcny who hurlds or inpr ov.s rtEEn. d *lm drc\ sdch M,k hnnsclt oi h$*lf ot rhmuSh I ir or hcr ow. cmpk,y..\.
<br />tmvidcd rhnr nrh nnF,vc,mtrh uc mr inckicd.rollceid l.r \rlc ll howcv.rrhe hildiryor iq,rov.rcnr n$kl *ithii on. ytr
<br />olconrl'lclion. rhc Owncr tluildcr *illh,E lhetudcnotpmlinsrhlr hco!+cdU fr hild or nnp$\r thc poFiy for rtE purqxc ol
<br />I. s\ o*ncrotrhc pop.ny. mcxclusivclt conrr.ri.S wirh li.ctrsd contrdcttrsr' construcl rhc proFrr lScc.70il4, Btrsnc$
<br />arxl ED{sshoCodc, lhcContado,'sLiccnscl-.wdocsnoraj,plrrorn.*n$orr(,pcnywhobu,ldsorimlotsrhcrcon.
<br />..d who .onra.h ror sxch rbjccB w h, conhn lo(s) lcctr*d nusudDrro rhc Conlracrois Liccnsc Ljw)
<br />I r.r..rpr u.dmsc.rrn .B & PC. tu.rhi{rcason
<br />I)"lr O*ner
<br />\!(tRl(FRS CI)l\It'FNSA fl ()N
<br />[lg.rLBM!(D
<br />I tur.b) rlln'n undcr n.nr!ry olncrrryonc ofrho f{nkrsi',9 Jc.lrrrri,,n:
<br />-l
<br />hnvc od will nminrlin r Ccnilrorc oi cl,nscnr t, Scll lnirrc fq work.^ .o ltf,nsriotr, .s I'ovidst l{'r by 56l ion 3?0o ol Ue
<br />Labor Codc. for lhc pcrlbanlncc ollhc work lbr whi.h lhc ,)cnni n nsu.d
<br />I hnvc rtrd will.ri ain w.rk.ra c..r!.ns,n,n insumftc. {s rcquircd h}Sccrion l7ll0oflhc lj$or Codc, for thc f[rlrmrn(c r
<br />rhc *o.k for whi.hrlrispdnir is nsr.rl. My wurld\' d,nIr.n$ri.n nNUrurcc.rris aniFlictntnhcr trrc:
<br />-l
<br />ccnilyrtur in rhc Fdi,rrorc ofrtc *ork tr wiich rhi\ pcrmn is issutd. I shdll nor cnDlo, any Pcnon in an, mr.mr
<br />\o rs ro bc.onr lubjccr k, tlr rolkcr $ntPetrn n,n hss ofcolitorni!. and aam rhDr ifl sh,rld h.nnnc suhJ.d h Ihc
<br />wo crs.onrp.ns.lion,rR)vhn,nsotScclionlT00olrhcLihnCodc.lshrll.lbnhwiih..nr!ly*irhrhrs[ovhions.
<br />IVAkNINC lJLr,. r, {.r 'qorlc^I subjcct an cnlloycr lo dj'ninDl FMIi;1 rl
<br />i coZxd!ruq$ * e\ni<tcd t lti.ivil ri0.\ up n).ne hurll.,1 rhou\xnJ
<br />2.b
<br />DECLAAd.ION
<br />I hcmby rfiii,nondcr pcnrliy oll.rjort rhnr I a li&n\.d u dcr fn,vnion.t C-hrnrcr 9 rconrnrming sirh Sc.rion 7(xD) ofDiv$ n:l
<br />oi rhcRusincsxndProfcs\ion\G c- rd 'nrli.cnsc n in tulltu&ralcllrcl.
<br />)+
<br />IaNEIAUCIIANIINDINCII;INCT
<br />I lrm$y nflnfl und$ FMlly or r.rFry lh,[hcrc h a condrudiotr kndiq a8ch.-y f{r rhc pe antu .. or ihc worx lor which rhh Fmir ii
<br />issucd (scc. lO9?, Civ C )
<br />Lttuc NLDscrA&riIa!
<br />lhcnty rinm rndd p.nrlry ofp.qury Dnc ol rh. folbwin! dRlddidsl
<br />Dcnn,lirhn Pcnnil\ A{trslos Norilicnrion F.dcrrlRcs lx!iutr (lirlc tl1).l']rd6r
<br />Rcquncd Glr.r.lNorirl.di{nr
<br />I..nilyrharrhc ri{ctul rcgulariotrs rgftlrn8 $hcsros tcNlrl.rc nor lPr,lioblc k, rhi\ pn*d
<br />_l cediiyrhrr I ln$ rclrl rhislrpli(lrnr ul\Ilrcrhrl ihc ly Birh rllCirrrnd co!trr!yr counryk'circruPoirltrordinanccs trod Srllc liwsrhriry ro l,uildins c
<br />$otr nrtuioftd pi.p.dy lor Lrspcclionpu,t'oss
<br />Applicot or Ap.nl SIEMIUR:cNe 'TB'I{-irJ ,/rs
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Roof Sheathing lltln ,4,q4A
<br />Shear Wall
<br />Framing
<br />lns u latio n/E nerq y
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />l\ilasonry
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />FINAL 7l?,olta \nJ 09
<br />Certificate of Occu pancy
<br />Notes Remarks, Etc.
<br />1.-
<br />bnJc,\ 4,,Jr.{
<br />Sublloor/VenVl nsulation
<br />Pool Fence
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