|
7
<br />BIJ1LDING- INSPECTOR RECORD
<br />SITE.WORK DATE 'COMMENTS OIVNER BUILDER DET,CARATION
<br />I hcrchy liltm un.ler pcnalry ol Fqury rlu I m c\.npr ift,n rhc Contr!.to6 l,(cn\c ll* r(r rh. hn!)*me !tu$n (S.u;0ll 5
<br />Arnncr\ .n'i Pnna$or Cdc): Any C y o! Counly *hrh rcqums r Frnir k' ron{n.i, altcr, mp!)vc. 'icrylnh o. rcl!tr an,
<br />(fldurc. rrrl,, rrs issuoE. r\o rcqun s rh. rml'ranr lar ru.h Fnnir b lllc a $3ncd dai.mnr rhar h. or shc tr hcnscd rai! r
<br />[, rhc !n'vr{.n\ I dE C.nklurn { l-Ecn*J Li* (Chrtrcr q. Comm.n.'ng wfh S.cton ,fi1 oi Divi\ion ] ol rhc Busrc$ lnd
<br />Pnn!s!,n\ Co'lc)orrhf,t hcorrh. r.rcnrfl rhcokom t.d thc bdsr\ ktr thc illc3.'t crcn n'n AnyvoLrrrnolStrirnT0.ll5byiny
<br />snpl'.rnr nraF-.m ruhj.rt thc rnpli.intloac'rilpcnrltyoinolBncrh lilr hunJrcJ ddlld((3500)
<br />-1,
<br />rs .wn.r of th. a ,lEny, or my cmpLyccs wirh wrscs as rh.t w,k ronpcn\aton, w l Llo tlE ,ort ad rrr (utE is nol
<br />urc cd orofltrcd lo! qlc(5(.7044. Bo\ircisdJ Porc$Dns Culc:1lf Cbnlrlcnn s Licnsc Law d*r not qDly lo an owncr of
<br />thc fln)Fny wh) htrd.ls d BF)k\ rh.E,tr.J*l who Jrs such u,t h'h{ll or h.rclttt rhoulh hn or h.r own.mpl('yccs.
<br />pi,vd.d i h{ such mporcnEnls e mr hrcnL'i or oltcGl ior sh I ll h,*cEr. rhc hnklin8 .r rl0n)v.md is eru wnhu onc ]et
<br />o, lr)trlllblr,n. rh Owkr Bufukr wdl har tlE hurJd ol phving rlEr tE or .he Jil Bn trit or mPn'r t]E Pot'cdy nr lh. PurFr* Df
<br />l. i\rwtr(r !n rhc rrolrny, dnrc\clu\rvcly.onti.ons * h l'{n{ d .onkr.!fl t) con(nd rhc loj..r (S.c 7tl.lr, nu{ncs
<br />rnd tt.iisrhCoJc:1h. Conkr(tr's Lrcnsc Lrwdoc( n.lllplyt, oowncr ol lrtlt y wh(r burlJr.r rmtov.s rh.rcon
<br />rtrJ sho .onrmrlsLr {,ch r8)jc.r\ wirh a o)nrr.n,(9 li.cn{d atrr'uinr r, rh. Onrocntr s l-ircn\.I-aw)
<br />I !m.xcmtl u",lcr Scdn
<br />!rc8[E8S:.CA!EE!SATIO!
<br />IEgLAXAIION
<br />I hcr.hyrlltrnrn'lrrIinrhyot$4uryoncofthcl.ll,)wng,lc.l rrnn\
<br />-l
<br />hrvc ril will roi' r'n i C.n i.arc .l C.nlcnr h Scl! ln{trc i,tr workc6' cotuF_n\d n,n. !s Pn)rlle'l li,r hy Su n,n :l?m ol rhc
<br />L rtr C,rlc. lhr th. Il.dnmncc ol rh. work ktr wh(h rh. pcmnr s 6suc!
<br />-l tuv. rnd w' ll h,mrrr woikcr' L.mp.n\an n nsulrtrcc. rs rcqnmJ hy S&r on lll)0 .l thc Llhor Ctdc, fu rh. JEdnmift c ot
<br />thc work ntr*h'rhrhr t'.mn rs 6sucd Myworkcr t4-ni[k,, n,{trrR. rxnd rDJ |})l].y nur$rr rr.
<br />lr.n'ly rhJr
<br />'n
<br />rh. Il.rlormrnr.,nrhc work ntr whirh rhl( |{nnrr F r{rJ.l nLllnor cnitkrtsry tr{ts n Drnyn'anncr
<br />n, r\ i, lf,otu' nrhl.rr b rh. 'oltcN comncnslrn,n hw\oiCrl'llrnxJ. rtrJ rtr.c rh rl I \lrnrl'l $dom {'hj.(r brtr
<br />wo*cr\ onrlcnllri.n O Dvrhtrs ol Scclon llTlx) ol r hc lrhn Gxlr. l \hrll. nrnhwnh c mply v h rh,a pn,vtrr)n(.
<br />IIARNINC: IiIlLrc n, {cu wdrk.^ .o n n{ ii ruvcolc rr unh*Itr|. inJ \hrll \uhtLr !n .nDhycr b rimml rnrld\ xnl
<br />0vil lnr\ up t' o,r hundrcrl rhousrtrd do
<br />Stcru,.1076ol lhc L.htr C(rlc. mtcrc{ and
<br />b-r
<br />Lt( uNsEt) r'()Nl Rrl('1()R!!!! 8r!Mr
<br />I hcEh, lrr nn un i.r Fn,xy or Frjury rhd I.mL.!.*du ier !$vnn,n oI Cha/.r 9 (con.rmot q hSclron 70m)orDrvn,Dnl
<br />ol th. Buxincs lnd Pn,L$i,ns cl c, anl o,y lr.n\c a n full tu(t dhl cflc.l.
<br />'-i->,/65/Sgr-
<br />1-t L ',1
<br />cqNsralcuauEll)Ilc-acENg
<br />I hcrcby !fitrnu cr lEn.llyot pcrjuryrhrrrhc..isaconntucik)n lcnding aScncy ir lhc pcdnrutuc oIrh.worktar whEhrhh lrmir i!
<br />i\\ued (Scc .1097.C,v C.)
<br />lr1Jc,.^JJ.{
<br />-
<br />APPLICANT DECLARATION
<br />I h.nt'y.tlm undcr petrrlry ol perjtry om of rh. n k'wm! d( Uraliotrs:
<br />rxm)lirion P.rmr-Asb.slos Notiliuarn,n Fc'lcral Rc8uhrionr (1 L 40. Pd6)
<br />R.quircd t ttsol NdilLalr,n
<br />_l rn,l! rhr rhr Ld.rxlrpl$.tr\ rrtd.lrB r\hc(o\ r.n)vtrLr'. nor rfi,huhL b rhs Phic.r
<br />I.cnnvrl.r I lun rc rhsapplr tr,n roJ irt iltrrl[rh crlnr l!gr.cn)d,mply* hrllC va C.unry
<br />od'irh.c\ dtrd Srat Lr*\ r!y rnd CoDtrlylo cnrcr trF)n rh.
<br />ah)vc mtrhotrcd pnrp.ny ntr iN
<br />Appli.ant or AAcnl SiEnnl
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Venti I nsu lation
<br />Floof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Exl./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL El6/rcit /hi^?l/Zh\
<br />Certiticate of Occupancy rt UI
<br />Notes, Remarks, Etq,.
<br />ID/SIG.
<br />Forms/Steel/Holdowns
<br />1l h,[l\,6Y
<br />\\_-/
<br />lla ,7
<br />:
|