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BUILDING- INSPECTOR RECORD
<br />SITE-WORK ID/SIG,COMMENTS OWNEN BUN-DliR DEL('ARATION
<br />I hcrcby.flirm undcr pcnalry of pcijury lhrt lmr cxcnUn liorn rlr Contdri Li.cnsc lrw for rhc firlowir8 rersn (Scc?0.115
<br />tsusincs aM l'rnt$i{,n Codc) Atry Ciry or Courly *hich rcqunc\ I Pcrnrir lo c.n{dcr. rlrcr. inrroE- dctri,lth nr rclrir .'nv
<br />(rucrurc. prt, t, irs isxM.c.also rcqutcilhc aPpli.rni tur quchlf,flnn ro filc I \isncd ddc.rnt lhal heor \hc n hccn$d llrumr
<br />t, rhc pi.visions oi rhc C.nlrackn r l-i..n\cd l-,w (Cholcr 9. Conntun.inS silh Scction 7(xro or Div,sion I or rh' Btr'ih'* xM
<br />Proltssions C.d.)orrhnr h. orshc iscicnrpr lhcrciom!nd rhc h,\is rorrhc{1lu8cd crcnrrion atryvioIrionorsc.rionT0]l.5hvrnv
<br />anrrlicanrrrn d Frnrir \ubjc.lsrh. aptlicanr !o aci!illlnrlryolnor rm,clhu ri!c l[mlrcd dolhn($51x,)
<br />I. ff ostrcr of thc pr.Fny. or nry cnDloyccs trnh wuscs N lheir {rc o rFnsalion. wiU do rL Nolk Md rlF (drm ir n'r
<br />inl.ndcn or.rcEd nn sk lse.7o14. Busircss ond Prcrcr\ions Codc:]]lc Conrract, r Li.cnsc tjs docs oor alllv ro 0n o$ncrot
<br />rh.pn,Fny *lh burlds or in{'mrcs rhcEnr. dwhodosruchworlhimlcliorbcrsclforthtoushhhorhcrown.mphvccs.
<br />prornh,l rhlr su.h inrrolcnrds m nor inlcnncd n ofl!rcd tu sJlc I L howcvtr. rhc b{il itrr or iqn,lcmnr h sold wirtin oN Fd
<br />ofcoaDlcriotr- rhc Owncr Auil]d will hrt rh bun]cn ofrorir8 rhsr h. d sh. dil,Fl ltrikl or i'ryr)vc rt prufnv ror rlE PUIF'*of
<br />-l-
<br />a\ owr of rhc tioFfly. In cxclusivcly .onrracr inE snh li.cD*d rontrrr(rs i{r cotrdfl.t ttr Pmral I Scc 70U. Btrims
<br />rnd P$lcssk,nCoJc:rhcContactnsLiccnscL0RdocsnoroPplybrnosnnolDrol.ny*hohnild\orinrrorc\rtureon
<br />aml qho.r,nrm.Btrtrsuchntuirls$irnaCodEcb(nli.cn\cdDtrr{utrnlttrhcG,ntacrorsLiccnscL,aw)
<br />-l
<br />dniDrr rtn undn S(l
<br />D{le o*n.r:
<br />WoRXFRS' CONIPENCATX}N
<br />DECIAXAIIAN
<br />I hcrcby lffi rnund.r r.nrhyof !,crjuryom ollh. folk,wing dNldnlhns
<br />-l
<br />hrvc J *illtuinr r.Ccniimlcoic.nrcnr t, Scllltrsurc tu 8orkc6 c.n,pcn\arion. rs lolidcd lor hyS.tri( r1700ofrhc
<br />Lahor C.dc. lor rhc FrfornD.e oI rh. $o l'or ehich rh. pcnnir is issuql
<br />(it ins,ork.n.oilpctrsrliotrinruraNc.ns rcqlired hys.ctionlTO(,oflnc llbor G'dc. r'ot thc Ilcrnn@ cof
<br />co'nFns.rii,n in\rr.n.c .dt! aftl P.licy numh(r dca
<br />L .n(-0
<br />-lcunilyrhrr
<br />hrhc p.rfoi,runccollhcwork tbr {hich rhn tttirnir i\ isucd.I shallnor cmlJlov rny Pc^on inrn!rr ncr
<br />(, * b hconr subl.cr lo rhc sorkcn compdnsJr im hws or c.lilnrnia- dqcrhd ilIsk)uldhc(, {b}-dtolhc
<br />qorkcm compcns.rion pmvhioniof sdrion l70oof rh. L.hor
<br />WARNINC, Failur. t' NUic worlcn !.mp€n$ri{x, .ordrDlc an ctrDl.ycr t, di'niml Pcnrkis lnd
<br />civil ftrc\ ur k,.nc huid'cn lhouund tlo riDr.srlion- d{nBE.s ,s I'rov,f ..1 ..
<br />I h.rch, rfln tr d,riilry.lpcrjuryrhJr I r t utulcr provision otChafler 9 (.onnncn ing wirh S..rk 7otro) ol Divisn,n.l
<br />\a l. r' n,v ll..n{ i\ ii lirllnnr nlclli.l
<br />A2L-)
<br />?
<br />I hcEby rllirn und Fnixyofpcrjuryr
<br />nsucd (Sc. lo97-Civ C.)
<br />{ru.rionhndingalc.cylotrhctrrli)irrinccofrltwork(rwhichrhhrcrmii is
<br />ATELICANLIECLAf,AITON
<br />I hortyafimlndcr p.n,hy of pcrjury onc olrhc louowing d..lu,rnnu
<br />D.nBlitiotr Pcrnrih-Asbcsrds Norin alion Fcder.lRcauhtions l'Iirlc 40, PM6)
<br />Rcquncd Lcrrer of Norificarion
<br />di"g r\lrno\ '. itr rLM. n.r xptl.rbl. r, ihN pr"l..r
<br />nnr( i\c.rccr lrsrlrt).o rtnysirhsl ciryx d(\ y
<br />uthoflzc rcprcsctrrrrilcs ofrhis Ciry ind Cornry k, cnrs ulrmtlrc
<br />"*v"'
<br />4 ."t ,r
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathinq l/tt /t ('24//M-/tZ--
<br />Shear Wall
<br />Framing
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL t0/trl/t 6ztm 7fY
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc.
<br />DATE
<br />Pool Fence
<br />Flood Zone Certif .
<br />4eqr3
<br />2
<br />IfI
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