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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OlVNE[ AUII,DER DELCARATION
<br />I h.rcby rfitm undcr pcnalry,)l I.rJUry rhar Ln .rcDPt loo rhc Conrra(o6' Lic.n* Ltw fot lh. hU{'wing rc.nrn 1S...?0J1 5
<br />Busincs .nj Pdtsir Cdr.): Any Cily or Counly vhich rcqunes a lrmi ro .nn(n'cr- alrcr. ihptuvc dcmokli r rp rnv
<br />srnrcnrc.orn,rlo ir\ ,$uM.c..ts rcq(tcs lhc apPlicln! lnr ru.t Fm lo nbn srsBl n"tmnl rh h.or shc n li.cn{d pu*u,nr
<br />h rhc rovi$ons o{ ltr Conrracroa\ Liccnsd tiw (Ch.!tcr 9, Conncncnr! wirh Se_ri,). 7000 orDivtion.l oi thc Brsinds sd'
<br />Pmicsions Co'lc) or rhd h.orshc $ crcry)r lhcrclroh M,l rh. h*i f,tr thc allcgcd c(hfln,n Ary v,oLlionolSctlidn 7011.5 by lnv
<br />aprlMnr rr, a pcnnit subjNtslhc applicrr ro rcivnpcn.llyntnot morc rhai tiv. hundrcd douas (5500)
<br />-!.
<br />rr dwtur ot rh. ptulErly, (tr my cnployss wirh w3g.\ r\ rh.n erb comFtrsarion, *ill d rlr qdk o!.1 th. sr@rm ir n
<br />i.nJ&l oro,lclcd ttr s.lc (5(.70:14. Buiin.$.nd Pftnassons Colc:1hc O,ikrciDis Ldnsc Law 'lms nor rlply ro owmt ol
<br />thc nD[rny who tuiusor mttuB llEBu sx, wh' rtf,s s&h kl* h,hscltor hcrsllor rhn,uSh hir or hcr own cnlilottcs
<br />F,vid.J rhdr tucb ,qh)vcmnls @ lnn inrcBlcl or oficr.J li)r eL. ll h*rcr, ltr hlili.S or mlrdtm.r Lr $! wnh'n oft y.d
<br />ofco Dlcron. rh. Owrcr Ruildc! w h.k ih.6rd.n ol Fmvin3 rhar h. or rhc JiJ frn buill or im0ow rh. PDIdy f.r rhc ldqnsoi
<br />t. !s owner oi rh. prup.d y. am cxclusivcly uoot'crins w h li(ned .onla.bn tu conrldd llr pDjet (Scc 7044, 3u$rcs
<br />aJri Psr6ibn Crod.: Thc Cotrrrukv s Liccnic t-rw .lors nor {ply t. an o,ncr ol rtut'.rty who bu ds or ifrprov.s tlErcon,
<br />anJ *ho Lrnr,nk lir $.h pbilts wilh . Contmub(s) ltcnsJ ptnurnr rt lhc Conrr.ck, s l-iccn* tjw).
<br />I.m.r.h.r u crScluxn ,B.&PC.L rhhrcr.'n
<br />Itaarcrs:.collrlNs rlo!
<br />DECI.IIBAIIA!
<br />I lrrcby aaltm unJcr penalty of pcrjury om or thc rollowi4 delaarirns:
<br />-l
<br />h,!c dd {in mrhm. Ccdil-f,ar. oac.n*nt ro SclHBurc for workcE {onrcnraron. is nmviled fu byS&rirn 37m oflhc
<br />tibor C{!.ta. foi rh. p.nomc of rh. port l'or wtich rh. p.mir i! ilsucd.
<br />-zt hrvc !n j wiu nainrain workcs .onpcnsarion inn&Nc, as Equtrcd by Scction 1700 of th. L.bor Codc, tur thc Fctforllr,N or
<br />n'n inlrratrcc c.trrcr uJ F'licy nun$.r a
<br />-7t ue 6-4 A t bG7
<br />-l
<br />ccnity rhnl in lhc pcrlormancc olrhc work for whrh lhs !.rmil N ssuc'1. I shnll nor cmfloy any pcron in 2hy nunncr
<br />kr mbh.v)m suhjer ro rhe sork.tJ .omlcnsal bn hws ol Caliiom( Md +rc lhrl ill slnuld hNom sublcLlto lhc
<br />workcn (o,npcnrari,,n pnlvs'ohs of Selon l?m of rh. litrr C{rlc. I dBU. lorihw h connly virh rho* 0tuvrbns
<br />wARNlNc: trdilurc ro scutwortcn uomptn\aro. u'!c.rsc,r u.L*lnl. aBl ih,ll \uhjtcr M cnrPloycr ro (Minal Fnal'ts rnd
<br />.ivil nncr op k, otu hu, rcd ll[uson Joll{s (SlAr,fllo), in aJd flr n) lhc co\t cotrrtEnsltidr, iama8$ a\ ptuvid.d n{ lhc
<br />Sr.rn,n.1076ofrhc Lahx Cotlc, inrcrcd an'l atroro.r's f(\.
<br />V
<br />I h.rchy lfrm undfi p.nilty ol pcljury.rhar I
<br />pEg!!8l!MN
<br />In!l${'n)vi!on.lChaprcr9(r(,nrcncor * hSc(rtn,7lxx))olDrviv.n:l
<br />ol thc Blsirc$ and Prur.$n,"s Colc, nftl my liccnr t in flll foc ,J cael
<br />B /D j*3 7.1
<br />9./ 7D /2o
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<br />c-oMf ttt'tttrl Lrrottrt; lcetrt'Y
<br />I krchy rftum dnJcr Fnrhy ulr.qury rhrJtcrcHiErrucr n kn.linS !3cNy td rh. ldiamncc ol ihc uork n)r which rhir ltcrmir is
<br />nsu.d (Sa. l(y)?. Cir. C )
<br />ATTLICANT DECT,ARATION
<br />l [.nby all]m rn'lrr p.trrlry ofpcrjry on. ol rl[ fdk,wing 'lc(ld tr,ns:
<br />l)emolirnn P.irnirs shc!os Notilieali,!r tcJcril RcNuLrdr\ (1nic,t0. Prn6)
<br />RcqunJ k(crol NorlL otr
<br />-l.dilirh
<br />lhc i.dqal,csr'ldioN rcgddnr! 6lr(.srcmovrlrE nor {dHblc rolhnln,Fr
<br />\,.*rly 'hJnJ
<br />hJ\.e,J rhtr itrl(. tr,nsrl Jrc rl'r rhcil!,v. trrtotnrrr)n is tomd LPftc k, conrlly w rrh !ll Ciry $d c:$rnrv
<br />\r,'lSitlclrs(!c1. tr'g h,htrrl,lrnp ran{ruJrn, m'l h$chy iurhtrizc EFr\cnr.tlrcs of lhF (\ry ICornryb.nrdu!.trrlE
<br />rM nEtrri,,ncd 0!'pcny lnr n,\F.l,on I'lrl})scs
<br />Applic{ o.Ap€ltsisn;rue
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framino //3 V** fL:?ttJ \.A /b,t
<br />lnsulation/Enerqy ,d
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />F[oo( Zpne Certil.,
<br />W( VP,Pt4crl 3:t'2rtl Vuufue ,ub
<br />,1,
<br />VV';ts/v Vhrlw,EO
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc
<br />Set Backs
<br />FINAL
<br />8/tt/zo
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<br />titrJcir Nrm:
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<br />tJnJc.s AJJrcs:
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