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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OlVNI]R Bt]I I,DI]R DELCARATION
<br />I hcrcby rrir6 undcr pcn ry {n pcrjury Ih,! I m cxcml lm rhc Conlrlctor' Liccnrc lj$ [u rh. ,.lldwirre rcason lscc.?l]11.5
<br />Busincss x! Pnntssion Codc)r Atry Cily or Cotrnty shkh rcquncs a pcrnir nr sn\rtucr, rlrd, nnPm!.. dcmolkh or Fpir rny
<br />{fl.rurc. priorro ns i$uan.c.oho rcquncs llE Uplic0nl ,nr such Frmir l{, filca iisncd iar.'ftnr rhar h.otshc is liccnscd luNmr
<br />t, rhc pmli\ions or rhc Cortn t, \ Li.cn\c'l bw (Chr|,.r 9, Connncmins trilh Sccrn'n ?(xJO oi Division:l ofrht Busincsund
<br />Profcrsion{Codc).rrhathcorih.ncicnrprrhcrclron'ndrhchosisaorrhdallcscd.r.trprnnr. nyvn.rionorssrionr0ll 5hyrny
<br />,mli.rnr r{tr r ,.rmir suhF.N rhc iffli.0trl to,.ivil!.nDlryornorrrercthon fivc hundrcd dolh^ (3500)
<br />l.rsoqndorrrf,l]rt)tdy..rnrycnDk,yccs*nhsngc\Nrhcir$hNmpcn\.rion.qil!dothewoltararh!(drurnR
<br />idcMLrl or ofltrcd lor elc (Sc.704-1- Businc$ otrd Pmnsion{ Codc: f ic Conrrodois Licctr\c Lf,w docs N, arply ro an osncrof
<br />rhc popeny wh) huild\ or impror$ rtf,tuanr uxl *ho dm\ \uch io* hinNclfor hcrsrlfor rhou8h his or hcr owncmpby.{s.
<br />ln)lidcd rhrr {ch i'nptuvcnbnr{ m nor n cdc{ .r ollird tu sh. Ii. howcKr. rhe 6ui[ing or i'q]rolcn is $h withir onc ]car
<br />ofcomflcri(nr. rlE owmr Buildcr *il haE rhc hr(lcn ol noviir rhlr h. or rhc dil mr horkl.r mflorr rh.ImtLny for rhe pq$e of
<br />l.xsorncrolrhcpmp.ny.r'ncr.lusilcly.onk,.rilgwirhl'.c\.d..trhroFhconsrruclrhcpDjecr(SE7or.r,Bu\iru\\
<br />ond Pmlas\ion C.dc: Thc Conlrocr.is Li.cn\c l,aw do$ nor up!ly lo an o*ncr or0nrpdt who brilds or imtrovcs rhcEon-
<br />a.d who conhc6 for \uch Eoich sirh r Comn.k,n t li..ned punuanr ro th. Conrlcror's l-icen* llwr.
<br />_lom.x.mF u.dcr sdrion ,B & P.C. lbr rnis rcay'n
<br />Dal., O*n.r:
<br />w(rnxERs c()[tPENsATloN
<br />D}:IIAXAIIQN
<br />I hcrcby.flnnr utrdcr !.nrl'yofrciuryom olrh. iollowirB dcclamrions
<br />Ih,vc,nlwillntrinrain!(tnifrcalcofConscdroSclllnsurcr'nsorkcrrcon{cnsarbn.rs pbv .dforbyScclion370noflhe
<br />tibor Gdq f{n rhc !.{omn.c ofrhc work for *hich rhc Fmln k issucd
<br />I hnvc rnil*illmrinrain sorlfiJ .onrFnld ion insurln.c,0r rcquncd hySccln,n l?O0oIlhc ln&t c(dc. for lhc l)crfonMncc ol
<br />rh. w.rk r.r whi.hrhi\ Fjnnir,s isscd. M,wortcK onr!.nsdi6 irsurotrcc clricr and polic, nnmbcr ft:
<br />c,"t,, ' )74-T R Fur'O
<br />oLl o l,Lot'l O(- o(-2o(
<br />I.cairylhd rhc,rrfitrnrfrr olrh. sork ior shich thh D!.,nir h hsucd- I \hnll norc 'rloy rny r.non in.try nrn.cr
<br />s' tr l,) ticcotrr suhjcd ro rh. *trkc* ..'nif,n\f,rion l,k\ orCtrlir{mid, did.Fr.c rhd lfI shonld bccom subjccr l. rta
<br />sorkcrl coDpcn$rion nnvisn)i\ ofSc.ri,,n.l7([ ofrhc lihtr Cdl..l shrll. t.nhwilh comply virh rho$ povnion\
<br />lY nNlNGr railur. t' murc workcrl conDcns ion covcmsc ir onhwrul- d shnll subjcr a. cmployr ro ainrinol Fnalrts lnd
<br />.ivll fiDcs trp ro om hundrcd rhousrtu dollffi (Slu),Ox)). itr rddirion n, rh. cosr or..'np.ns,rion, d,.4cs.s providcd for thc
<br />sc.tion 1076 or rlr hhtr Codc. nrlcrcst md lnrEy s r!cs.
<br />(6(tl
<br />^ppti*^,, *- tLLh',4-r lott.cr Cat
<br />LrcENSUrcOIISAI:IOB
<br />DI:CI.ABTIIQN
<br />ol rhc 8u\incs rnd ltoltsion\ Codc. dxl nry licc { i\ i'r lnlLtur( dtrtcllacr
<br />*.r.,-*., - aon't1J'Li.cn,.ct*",' /3 Li.c
<br />A4LL( {.L c.,1,"1"e t 0 L Lo'/Tr'uc'r(La
<br />ATIU(ANLDECLASAIION
<br />I hod,y !8inn udcr Ii.mlrt ot pcrjrry ok ofrhc folk,winS d&lrationr
<br />Dcnblition Pcnnih Asbcsr.s Norinclrid Fcdcral Rcsuln' iinN l'I'nL ,$, Pd6,
<br />-Rcquiru{
<br />Lcllcr of Mrifi cnri.n
<br />-lccnilrrharrhcfcdcralagulari.nsrclardingasb6rosrnmvdmnor.rplicnblctolhisomj$t47cd 'ry rhr I hxvr rci,l rh'r ,ml{arion ontl { dc rhar rh. atrvc inloirmliotr is cotrccr I uBre lo conply wirh all Ciry rnd County
<br />nrd;aKcr strd srrrc tr$\ rlar'ne h hu,ld,ig !.n{ddhn.plrrrcby rurh.rir Eprcscnhtiles ollhh Cn, and Coutyro ctrrct rF)n 0f,
<br />sbovc trEnt'oncd Imlrn) lhr in\nc(rmn nu{!$r ./
<br />n orr.,",", n*""r"r**r*, /ff
<br />-
<br />^r" ' o s/ t t/ t N
<br />P" 1*,*"te,1^t). tL 40t^'+r/ T U Pe<J (4!-
<br />Set Backs I
<br />I
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Venti lnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsu lation/Enerqy U lr 116 de5?
<br />Drywall (t I I IYsT
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL @utoN-/6L-.,
<br />Certificate of Occupancv
<br />Notes, Remarks, Etc
<br />((B
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<br />CANSIaUCUITNIINITINCJCENEI
<br />I h.rhy sllirn u d.r Fnrlryofp.riury rh rhcrc is0connrudn,n hndingaScNyforrhcperforonccofrhe *or* foi whththh lfflnn is
<br />isucd(Scc .ll)97.Civ. C )Lun,lc':\'c-
<br />L.ndciq AdJE$.
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