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BUILDING. INSPECTOR RECORD
<br />oWNER B(JII,DER DNI-CARATION
<br />I hcr.hy 0ltuD undcr |crrlry oi ncrjury rhar I .n cxctrU li.nr rh. Cotuklna t-iccnsc t.s for rhc folhwn8 rcron (Sqc 701
<br />Busnr\\ trd Pmr.$n,n Codc) Any Cir, or Counr) r'hi.h r.qutcs r pcrn,ir n, connrud. alrc,. inDrovc- dcmon+ or rl).'n r
<br />,I
<br />struclurc. prior lo ns Nsulrkr, al\o rcqutcs rhc.pplicMr fd cuch pcmirro flc, sigmd {dcmnr rhar tEor shc ar lianed tlunuanr
<br />ro rhc J)(,vicior .frh. C.nrrt(r.4. l-i.cn\cd If,w (Chsrrer 9. Comnrreing wirh Sccrio. 7UX) of Di!hi..I .f rhc Busin.$ lnd
<br />Pmlcssions Cod.) or rhxt hcorshc iscxcnln rh.rcfmmand rhr l,rsi f.r rh.nllc8.d.bnDrion AnyviolrrionolScdiotrT0.ll.5byany
<br />.npliclnr ior r pcrnrn {rbrc.RIhc arpli.0 ro acivilpcndktornor nhrc rhri fivc hundod dollrs ls5ur).
<br />-1.
<br />ds oqrcr ol rhc pmFny. .m crclusivcly conlfucrirB wirh licci*d .oorrcro^ ro onnrcr rhc lrojNl (Scc 7()44. l,usims
<br />rM Pn ixstur Cod.: ThcConkrror's Liccn\c tr* &rcs nor lpplyr. anoencr oftropcny wh{, btrilds .r nnrmvci rhcrco..
<br />and who conrrocls ,or such nmjcclr wirh ( Conrncro(, liccn*d puruanr h rhc Conllacrols l,iccnc li*)
<br />l1r
<br />,er Sdion-, B
<br />5 tg
<br />I )1.( I tR \ ll()\
<br />I hcrch,airk,nundcrn!mlryoipslur,oncotlhchln,win8d(l[ i.n\
<br />-l
<br />havc {Dd will mrirhin rCcnificale ofConrcnl roScll'lnsurotu workcrl.ompcnsalion, r\ pmvidcd for hyScclion]Tff)olrhc
<br />Lrhor C.dc.lorrhc p.rlonMn.c oirhc wor[ ln which Ih. ltnnn i\ ksucd
<br />I hrvca.d will mrinrah workcrl comr.nsrrion insumm.. $ r.quir.d hySNrion l70O ofthc tjbor Codc.lor rhc rcrlornErcc of
<br />lhc sort to. which rhis |l.rmn is isscd. My*orkdC comp.marbi iNurmccmicr uld ,rlicy .un$cr ec:
<br />l'\f (r
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<br />ccnilr rhlr in lhc p.lnmuncc ofrhc work lar rvhich lhi\ pcrnrir ir is\urd. I shall nor cnrpk,, nny Fr{,n in rny m,nncr
<br />v, n\t, hl{otu suht cr k rh. $rtrkc^ (nJlttrn$rn,n bss olctrlilomia. nd l8ft. rh ifl rh.uld b(oim sublcd k,nE
<br />!.*crs conrl.nsdion pi()viti(, s ol Sccr i(,n l70l) ot rhc Lrnr Or)dc. I stu l, tunhwith .onrdy ' irh rhoB prorisi{nx
<br />WARNINC Fnilur. k, s.urc s.rkc^ cor,pc0\trri , .Ikr|lgc is unlawtul. rnd shrll subJ.cl rn c 9l,'y.r b .ri,niMl tf,n0hi.s o'l
<br />.iril linc\ up b om hurlrcl rhor\rnd dollsr\ ($lol).(x)0). h rddirin n' rM.on of.o rr. \In,n. dxtruScs rs tmvidcd lor rhc
<br />Sr.ri,tr,.r076ol rh.I lxtr(ixl.. inrcrcn rRl rttrmy \ l.c\
<br />)ll.,l r t
<br />I hcEhy rllt r x.dcr pcndry . r p.ijuiy rhdr I rn li(ncIl xftlrr povhi.n or Ch,l,r 9 (smnrncing wilh Sd ion TuJO) of Divnion .!
<br />ot rhc Dusircss and hrfcsions C.dc- arxl my liccnsc h in full r'ore !ftj cfid
<br />raluBusuaNrl;NDllri-&91;Ntr
<br />I hrrchy rli'm trnnrr prrulryorpciuryrhrr rhcrc is,.on{tucrbn Icndi.! rgctr., lnr rhc !c onu..colrhc sork inr shichrhn pcrmir is
<br />nsuc (Scc. .lO9?. Civ C )
<br />AITUIAILDECI,A.EAIION
<br />I hcrcty dlinn undcr lcnrlry ol pcrjury orc olrhc lbllowin8 dclar{lions
<br />Dcnmliri.n Pcnnirs^shc{o\ NotiicrinJn Fcdcril R.Culrri(nN lTirh 40. Pdd6)
<br />Rcquncd L.(cr of Norifi .ar.n
<br />I ccnii!thol rhc lcdcr.lrcSulolions rcB:udir8 asbcsto\ rcnnrvd ffc nol upli.!hlc to lhis prcjccr
<br />lc.dillnrr l hrrc r.tkl thi\ tfl1i ri,,nn (rrcrhrrrhcrhir. ini)nr i,r n.orccr l r!r..n)co'nplt{ir[rilCiryrtd Cotfry
<br />abovc nEdnrEd fmNny |or ins
<br />Apl'lnrnr !tr ,\r.trr siAurur.
<br />SITE-WORK DATE IDiSIG.
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Roof Sheathinq
<br />Shear Wall
<br />sFramin
<br />lns u lation/E nerg y
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lvlasonry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL L 7 th-ft) 4/1)
<br />Certificate ol Occupancy r-l
<br />Notes , Remarks, Etc
<br />{
<br />ru (aa
<br />COMMENTS
<br />Subf loor/VenVlnsulation
<br />Pool Fence
<br />Flood Zone Certif .
<br />--T_------
<br />l. n\ ovncr or'rhc lopcnr. or ny cnrloyrc\ wirh wusc\ us rhcn qnc compcnrdn,n. \,ill do rhc !,ork ud rhc {Mr@ I ton
<br />imcklcd orollcr.rl frtr elc (S( 70,U. Aun.cs\aid Pnirc\snnNCod.: Th.Conta.rtr s Li.ch\c t-aw docsnornmlyr' orkr.t
<br />rlrpm,xny wh, hrild\ fr inlPnrvr rhcNin. d$bl,f,s\trchsrtrkhin,\rll'nrhcn.llorrhR,ughhi\orhcrowf,c rrl,,rcc\.
<br />Imvid.d rhar such iDpnxlEnh m Bn inlcnlFlnoitcrcd r.! srL lt howc$r rhc ItriUinB o! nl{,mrmm is ekl wirhn onc rr
<br />ofco Dlcri r, rh. Owncr Auikld s lhn\rrtrburdcnofp()vin!rhdhc.rrhcdii,xnt{ild.rinqnrtthcpmFn}lorrhcpuqnsof
<br />D,r 513, l/ I
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