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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OlVNER BUIT-DER DF:I,CARATIoN
<br />I hcrchy rl,lr trndcr pcnaky,n pcrjuy rhat I 3m ctcmrr lioh rh. Conti.(rom' I-iccnsc l,aw ttr rhe lnllownE tcrn,n (54.70!15
<br />Busm$ anj Prr'c$im C,xlc) Any C v nr Counry whi(h r.qut$ J pc.mir n, conndd. )lr.r. imln*c. &nn'lish or rcpar my
<br />dflcrurc. lriro ds isn .c. ikorcquiE\ th. !!rl(rnr tu surh !.rnnr k\ filc ! !i8md (ircnEnt rh,r lf,or it s lic.n{d !trr$rnr
<br />b rlr pk,visnn\ ol rhc Coikrck" r Li.cnscl L.w (Chiplcr 9. Com rn.ire qnh S..rtrr ?U)0 ol Divisi{'n I ol rhc Bu\in s md
<br />Pn,li*k,tu C(xl.)orrhdr h.orrhc t crcnrnl llrrclromlnll lhchrns lff rh. ihtcd crcmdio. AnyrnlllpnoaS.(kn'70.r1.5b!any
<br />xpol'cadntrrpcrmirnrhjcchrhc.mlicrnrbr.ivrlpculryormrmo'cllrtrtivchunnlcJJolh6(S5m)
<br />-1.
<br />x\ owi.r .f rh. l)I'J{ny, ,tr my cmpLryecs wirl wa!.s r\ rftir \)1. conr$n\.r ttrr, s l no lh. work r.,l rhc {n.rDrc r Nt
<br />Inkr cn.rolilrcllirelc(S(?044,Bu\i,rc$sdPftn.rednsCdl.:lhc({nrrs.trr\t-,ecnrcLxwd({snorapplyhrnosncr.l
<br />rh.rm)nny wl hurlds or ml|I,,rs rhcRm. r'l wlx' JE\ \uch wut* hnnscll or hcrell or rhruofh h'r .r hcr.wtr .n,Pl,'yccs.
<br />pr)vklil rld \uch ihtnntmns s Nr rlcdcd or ofrcEi lbr \rk lll l'i,wcvcr, rh. htr,llDA or ir{'n'rcmnr i\ $ld qiltun onc ycf
<br />old)nrplcrion, rft Owm, Bu,l'lcr w,ll hdvc drc bur&n ofpn'vin! lhd lEor nrc Jn nor hudJ or 1nlvorc lhc lrnFly tur rhc ouqrre ol
<br />-1,
<br />a\own rorrh. lrl)rcny, .m cxcl$ircly ronk&ins wirh I'ccn\cd lotrtrxcbn b.on(n rh. rojccr (Sc. xw. Bunrc$
<br />{'rl P! isbn C{xic, 't h. cl'nr,rnn 1 Lt.nsc L.w dms nol ltply rr' !n o*ner or F,pcny Pht) bu ilds or iarlroEs nrrcon.
<br />an'l who r.nn,ctr tur such pruflls wilh a Conrr&tn(s) liensc't pusurr rolhcConlrtktr'\ l-i.ctrE lf,w)
<br />_l imcrcnrpr nndcr Scrtlo
<br />lvoa(E8stror.l[ENtaMN
<br />DECLARATTON
<br />I hcrh! rftn u nJcr o.mlly ol Fcriry onc oi ltu dn)winr ncrb, ]r n\:
<br />-I
<br />hrv. and wnl nuinrlin s Ccn iltsrc ol Conrnr t' s.l[1.\u6 tur w.lkor lonpctrmrn,n. ii F)virlcd for hy Sccrion ]700 of rhc
<br />tjbor Codc. ,nr rh. Fctulfutre of rhc woIl lnr which rhc fcrnnr N snrd
<br />IhrvcanJwillnumrainso.kcrronDcngrtr,nin{ur!n.c.rrt.(luircJhyS.cr('n.17&)orrh.Lftorar)'lc,ntrrlEPcnonmn..r
<br />rlr work Ii,! whi.h rhn pcm is trsu.d My woikcrt .onlt'cn$lin inMan ccar'c' rx] Ihicy nnn'bcr {c:
<br />lts kt=t t^ZOZO -2\
<br />Iccrr'lyrhir lhct^-n.nun(colrhcworkntrwh'chrhi\|frnlnrssu,c,l I \hrll nor . lpl,)y riy l'.r.tr ir iny nr$nc.
<br />(,!shbcconE\ul!c.rbrhcw(.rironllcNIirnrhw\.lCdrlorrrir.rn'.13!'!crld,,I\lkrldhcd)m{hjcdnrrlf
<br />s.rleF.onp.nsrrn,nF,vrnn\olSccr(nlT0Odlrhcl-ahtrC,klc,t\hrll.nlnl'wirh(.nflyqirhrhocnn)vi\ion\
<br />IVARNIN(;: Fdlurc ro c(urc w.rkcr' .ompcnstrri,n, .ovcrrgc '\ utrhwftl \hill suhl.tr rn c l[lk,yo n' (f,nur pcMllics and
<br />(tri ln'.\ ,0 i! otr. htrr,lr.,t 1!i^.trtr| ,k'l],tr\ rSllrr).rrr)lr) tr, .tr],n$ () rh. L!^r .l .onBrlrrk)n. Jrnrr.\ .\ pn)vkl.(l lor rh.
<br />nc. dck\rrRl rr(trrf,!_ \,..!
<br />I ncrcby rl&nunlcr Fndlry ot lcrrury rhar I !n [ccnaal unncr !n)!i\n'n o, Chafld 9 (cohnrco(ins wirh Sccrion 7O0o) orDivron I
<br />ot lhc |unncs.nd Pmfc$ions CoJc,,xl ny hcnsc r ir lulllor.. {n'lclltct
<br />^o
<br />I h.rhy !l&m un,icr Ft,xy or pcijmy lh{ dEc i! a.1,nstn'.lion hndin-s ,scfry tu rh. p.rfo,rwc ol rhc *o 16rvlri.hlhE Fnn,l s
<br />isucd lScc. .109?, Civ. C.)
<br />APPI,ICANT DECI,ARATION
<br />I lf,'!$y rlllmr trnicr pcn!lry oipcrjury on. olrhc n,ll(iatrr$ Jccltflruts:
<br />D.nr)l trr l'}$nnrl^slrsd\ No|lrlri, li.JctuIR+uhhdtr\ (1'rlc,lrr, Ptr 6)
<br />R.qutrcd lrncr ol N({ rltrndtr
<br />l.cnil.vrhri rhcf.Jcr rcpul^lotrs rcganlir8 !she{os lcfl$ulrrc norrtJnlicftlc k) rhi!!nrjccl
<br />I cdn-vrhd l h.v. rca.l rhn aprli(xrion&l n,r.rlfi rhc ah'vc rnbrm inriscotrc.r.l,smk,conflywirhallCilyrn'lCotrniy
<br />drlrrrtrc.( r Sr,l.l,rwsEL
<br />'ng
<br />n) buildi',!.,.,.0,.\.nrrrr(\ ol rh^ ( fv.nrl(inxnvni.nr.' trrin, rh.
<br />rllivc,tunLoncd l]()Nrly tir msp.{tinr
<br />a-?,\rpli. nl r,\BulSir nhn L ft t/zfzu
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Sublloor/VenVlnsulation
<br />Roof Sheathinq /- r- 20 Dffi,.b,
<br />Shear Wall
<br />Framino
<br />lnsu lation/Energy
<br />Drywall
<br />Ext./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 />I I
<br />FINAL -J.1.*t llt lzo Dftmot*ffi
<br />Certiticate ot Occupancy lr
<br />Notes, Remarks, Etc.
<br />l-'J.-'. 4JJ:rr
<br />--
<br />UFER Ground
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