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BUI[DING- INSPECTOR RECORD <br />SITE-WORK DATE tD/stG.COMMENTS OWNER AUILDI]R DEI,CARATION <br />I h.icby affiih und.r pcnalry ()f !.rjury rh,r I m cknpr fmn rh. Conkfun Li.cn{ rj* f{, rhc f.ll.wing rc.sfl (Scc.701lr5 <br />au Nss and Prufcsion Codc): Any Cily or Cou.ry shi.h rcquncs . pcnnil lo .onslrucl. altcr. nnpolc. dcnmlth .r rcp6n y <br />nodure. Driorlo irs hsunn.c. ilso rcquiEs lhe uprlicnnt lor suchlcrnnt ro filcs ristrcd slalcmtrl rhlrhcqsh.irlic. \cd rrnnnnr <br />r. lhc pnvisions of rhc Cont.d.rs Liccnrd Laq (chiflci 9. connnrNins wirh Sccrion r(XD of Divnion I oI rhe Brtrincs and <br />Ptufc\sion\ C{dc)or rhar h.or\hc !cic'nr rhcr.tromandrhc baris for rhc xllcgcd er.hlrion Aiylnn.rionofS(lk,n 70115 hya.t <br />0pplicnnr for a pcnnn subids lhc lprlicruroacivilpcnrhy.rnor,r{.rtumliv.hu.drcddollih(3500) <br />I. us owncr ofrhc popcny, o nrc'npk,,ccs wirh *sg.s !s lhcir {nc cotrl,.nsdnrn. qilldo th. tr,lk mllh. iuxN h nol <br />inrcndql o, oillrcd for salc (Scc 7044. Busircs.nil Prorcs*otrs cftlc Th. Conrr.crois l-iccnrc l-ow des nor apdy ro mo$ncr or <br />th. rropcdy who builds or nrytuvc! rtf,m.. alxl who d{f,r skh woli himsclfor h.r{lror rhftugh hh orhf Dwn crnployccs. <br />pr)vi{l.d rh3r such iDpr ovcn$rs nc nor ir .ndcn or oftcr.d ftn sL. ll tu]rvd. rh. htriuq .r nlrlrorcnEnt is sld wilnin orc Ns <br />olconrl)brion.lh. Owncr Build.r willh!rc rhc budcn ofpmving rtu[ hc or shc d]d nor htrild or nnpoK thc r$Fdy for lhc purFc of <br />-1. <br />Jso*ncrollhc pntlrry. !mcxclurnrlyconrrlcrinA*irh I .cf\c.l coDhcktrs ro connn'.r rh. nmrci rsrc 7(!.,1.Iluetrc{! <br />Ll B()fc*6nCodc lhcConr crn s!-iccn\cl-JwJocsnorapnlyb mo*T.rofp'i)tx r sho btr rld\ or i'nl)nrts rfur c.tr. <br />atri wh. coMiclsld su.h tml(ts wirh r cotrincnr( n li.cnscd Dusurnr rorhc (onrmcrd s <br />c.1../--- <br />DIlCl.,\RAtl()N <br />I h.i.byamriundcrl.n,orr.rjnryoncorrh.tdLwinsdcclar.lio.r: <br />I h,!r mJ will tuinrain a Ccnificdr€ or C.nrcnr ro Sclf lnslrc {or *.rk 6 L$nF.{rion, ds providcd for hy Sccrion 17(x) .f thc <br />ljbor C{xlc. for thc ll.rformmc ol thc qolt tor whi.h thc pcrmir h hsucd <br />I h|v. and willf,aini.in Rorkcrs conpcnsdrion inluran.c, d3 r.quncd by S..lion 1700 ofrhc ljb.r Codc. to. tl'a Frforrurcc ot <br />lhc work lor which thh p.rnir is issuol. My workeJ sqx.sarion insurme .dtr od poli<y numhcr ac <br />-l <br />cenil}lhar inlne neri.rronccolthc *.rk lor whichlhn p.lnit k knrd- I \hru nol cmploy lny lersotr in Dnynrtrftr <br />n, r\hb..o.,csrhFcrhrhcworkc cory,..sdbn lassorcnlifomir and rlrc rhrr irl stbtrld h..onr sul,jcct rorhc <br />qorkr' .ontrn\ ri(nnn^'\ii)tr\of Sc.rnn:17(x),,rnrI-rhtrC{{1. I nRl hwirh otrrly silh lhoc pnlvisions. <br />WARNINC rrihtrc r. surc v cr{ comrcn\olion covemr. ir utr sl ll {'bl(r rn cnrh)y.r fu di ri'il$r'lri$ aid <br />!2rtl ail&t <br />I hcrcaynllirnr und.r lcn,lrrorFrJUry rh r om li.cnkn und& pmvhiotr of Ch.rrc, 9 <br />of rhc Atrsi.csnnd Pmfc{rn,naCod.. arl ny li.cn{ is in fullfincd mdcli&r <br />Nirh Sc.ri,r 7{xx)).ll)nni(,, I <br />I '(tr.c lutr.hd <br />- <br />Irole: ('onlriclor <br />.CANItrIJ.(:IIaNIIIIDIN!.&EITM;.I <br />IhcBbyarfirnuncrpcnrlryofpcrjrrrrhnrrhcEtrcondrucri,nbndinsrsrncyrdrhcp.rtunuNcorrhcworktu$hkhlhnpcrniris <br />nsucd (Scc 3097. Civ. C ) <br />AfILISANLDECLJIAIIA! <br />I lurby olnnn undcr pctr{lry ol pc.jury onc ollhc rhllorins dcclarori.ns <br />tXmolilion Pcrnrils.Asb.slos Norific.lion Fcdcr!l Rcgullllion\ (1irlc40, P.n6) <br />Rcquncd brrcr oi Norifi cnrion <br />I conilyrhrrrhc f.dcrrlrcgulrrion\ rg rtlinE r\h.n.srcnn*rlrr. nor rpfl'c lcbrhispx,f.r <br />-l <br />ccnilithar I havc r{drhn qplicariotrnnd rrddhrllhcntrrc in ion is.otrc.r I rgN b.onplywnhnllCnyrnd C.unry <br />nr!inunccs Srrc Lrqsrlarina ro huildinaconrudinn. <br />0i.,vc nf, nncd rnncdy ior nsncdrcn n[nNcy' / <br />nrr."r"r* nO"rt*" rr* X l'fttl <br />P.mit.. n.n. ( prinr ): <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVlnsu lation <br />Roof Sheathin s <br />Shear Wall nFraming Qenh <br />lnsu lation/Eneiqy <br />Drywall O"*k- <br />Ext./lnt. Lalh <br />Brown Coat <br />Ivlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Q puty Final Report <br />Engineer Final Report <br />FINAL v)tflq 1 i,ln^.-.rl <br />Certil icate ol Occupancy r1 UU <br />Notes, Remarks, Etc <br />d/-| ./-\ <br />t a4 <br />Flood Zone Certif . <br />?b,/ <br />D 1ant- <br />VU <br />tt <br />tt