|
BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Sublloor/Vent/l nsulation
<br />Roof Sheathino
<br />Shear Wall I I I
<br />Framing (tl rt r-l 1-l
<br />lnsulationi Enerqy lt
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Itrlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.i:
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />Ir
<br />FINAL blt"\d
<br />Certilicate of Occupancy I
<br />Nelqst Remarks, Etc
<br />t-o \frWEA
<br />D D
<br />)s .J5J
<br />-:,.
<br />.=
<br />OWNER NUILDER DEI,CA RAT'ION
<br />I hctu$y !ftlrn umls |ttrrliy i,f |trjury rlttrr I rcrc lPr lronr rhc Conrracror\' l-icci\c l.r* f{n ihc f.llr,wing runr., (SN70.115
<br />Bu\ir.\\ n l P(,fr\\i.n Cod.): Any C[y or Counry $hich rcqutc\ r Firnir ro ra,n{rucr. alr.r. i'npRn.. dcn.]i(h or rcprtr atry
<br />Inrnrc, lY(trt) irr is$h .c. rl$ rqurts rhc.ptlicr lar skh Fnnirro flc. r8t&i narctr rh{r hcor shc h liccnscd pu^urtr
<br />k) rhc ptuvtnnr\ ol $r c{)nkrcktr s Li.cnrd bq (Ch,prcr 9. Con,nrncinE *irh S.crn,n 7dX) Df Divi\n,n I ol ih. Au(i.cs rnd
<br />l,ron\1i,)nsCodo orrharhcorshc ilcxctrrpr rhcrcl'rondnd rhc bdlis rbr rhc allcpcd cxcnrri Any violari.nolSccril)n?(,.115 by rny
<br />rlpli..nrnfuNnnirsuhjc.(rh.ll)Ili.rflr,rrivilr.trllryofnornxRihrnliv.hxdi.dd.llr ($5(X,
<br />-1.
<br />$ owncr oilhc pllxnl. or nrycmployccs wilh srec\ as rhcn nnc.omp$srlt,n, willdo rhc sork md rlr (rucx'rc t nol
<br />inr.dhd or orTcrcd lor slc (sa.7t)44- Busines rnd Pnfc$ions Cdc lhcCodrcctois l,iccns |j* docs nor applr ro ,n o*ncr or
<br />lh. mrncny nho hoild!or im,mtrs rhcEnr a.d who d,B {kh sin him\cllur hcrsllor rhou8h his or hcr.wn cmplorcc\,
<br />providcdrhrr \uch nnni(ffr.rsm mr ificdd or.ft tf etr li h,w.hr. rhe huikting.r i'rytuv.mnr i\ skiwirhrno c ]r.n
<br />ofc.n!,lclhn. lhe Owncr Buihcr rill hrw llE lDdcn oi rovi,E rlur h. or shc dil mr huild or nqrovc th. ,mlgly for rnc lrurFs ot
<br />I. osn.r of rh. Frpcny. !m cfthsivcly conrEcrins wiih licenscd conrrackn\ k, con{ru.r rhc Ftcr (sc. ?0,1J. Bu\m$
<br />and trrofcs\i Codc thcCorlra.in s Liccnsc Lrs dols nur pplyb dnovncrofpi(r.rlywh. build$or nnprorc\ ihcrcotr.
<br />rid who onlrucll for such prcrccrs *iln ! Conlmcn,( s) liccnscd luBuitrr lnlhcConrraclor'\ Licens L{s)
<br />-l.mercnDl
<br />undc, Scctnrn- It. & P.C rorthnreawn
<br />!)ale O*n€r
<br />uaax[8[!j)!lfrN$llaN
<br />DIICLABAI,II}N
<br />I h.rcby rllirnr undcr Nnally.f t^-rjuryo0c ofrhc rbllowirs dcclir iors
<br />-lhrlr
<br />ud*illtruirhinu CcnilictrrcolCotrstrlio Sclllmurc lor workcd .onrt^-trslrion. n\ pmv cd tur brSccli,,n 17(xlorrhc
<br />L.bor Codc. ior rh. llrlnirMmc ol Ihc sork ior which rlr rcnnir Li isslcd
<br />rhc wo hr shichrht pcrn l is i$ucd My$ork.A conD.n\rlior in\urancc crricr r{l poli.y nun$rr {c:
<br />d./,/
<br />I .cnify rhtrr nr rh. t).rnrDht.c ol thc wolk i, ehr(h rhi\ |{i,nn is i\{rd. I sh.ll f.r cnll,oy ity fcsot ir rty mnrncr
<br />$ rbhcsrrc {'nrccr hrhc *ortcn co.rp.nsrrit)tr h*sofCilin)rnii. innt'3rcc rhrlirl shn'ld
<br />sor[cr\' conrp.n\ari('n fovni.ns oiScdin :]?0r oirhc
<br />wARNIN(: Ililurr () \r.uc $orl!^ .on,ruD\rri(trl k,tcr t' d'ni'rillaiilric\ rtrrl
<br />'u.rl'-l rh, r.tr L
<br />s,.,,- rLr',,, 4"r,nl,-,,r .-,"\A,","5/a1te
<br />rn, drn'rg.\ r\ I'rrirld kr rh.
<br />I hc('hy nlrtnrn cr Jtnrlry oi I[rjury lh( Irnr liNnscd
<br />of rh. rl,,\i'Hsrfti Pr.L\{i,,n((i'd. r
<br />Ihcrchy {Itn unicr pcnalry oipcrjury rhrrihcrc n
<br />inicd (Ss 3097. civ. C )
<br />olrh. $rtrk f.r shi.hrhi\ ncnnn r
<br />l.r'r l,vrlHr rh.l.rlctul,.g llri,)tr\ tug dn,g r\[n,'\
<br />-l
<br />ccniryrhd I hvc rcadrhir h cotrccr l r8c ro conrply *irh xllCiry d
<br />orlirrrccs rnl Shr.lrqs rld rL]ncscrlarilcr ollhn Cily rnd C.unry I
<br />rhnr fu rnn'cd pir)tr ) tur
<br />Set Backs
<br />UFER Ground
<br />,t/
<br />I r.
<br />r rh S.Lro,7rnr) ,,ll)\Ai(rr i
<br />r)-16{+{ /trp6J \AA\/41?f / olz
<br />LI
<br />APPI ICANT DECI RAIIoN
<br />I lEarby nltinn undcr pcnrhy of pcrjury onc of
<br />'hc,olhwnrs
<br />d.clntrriotrs:
<br />DcNniion PfnlnrAsbrstos Notifi.ation r,cdchl Rclul,ions (Tirl. i0. Pff6l
<br />-Rcquircd
<br />Lcrrcr oi Nolifi c[tiotr
<br />(n,i
<br />I ]
<br />I
<br />-T------
<br />tt
|