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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNI'R BUII,DER DET-CARATION
<br />I h.rcby aflirm lndcr prMlry i,r p.rjury rhar I n!.kmfl rrdnr rh. Conh.kri Licctrsc Lrq ln lhe nnhsir8 rcrvnr (S(7{)l}15
<br />ax\incsl ,id Pn,fc*ion Codc): Any Cily.r Couhry whi.I rcquncs a Fnnil lo connrucr. a,t.r, nnprcvc. dcmlish or Eprt rny
<br />nrudue. prdh irs rsu cc. nlm Bquncs rhc {ppli.rfl n su.h ncflnirto nlc a ligncd srlrcnrnr rtur hcor shc ( li..n\cd l]U^ninr
<br />h rh. Frvtion\ of rlt (..nrtudor's Licciscd ljw (Chrrrf 9. Connncmir8 wirh Scciion ?Ul0 oi Division :l of rhc Businr$ and
<br />Itolcssions Code)or lhrr lEorshe iscxcnd rhercr'romrnd thc btr\h lor rhcallcscdcicnlPrn,n Anyvn'hrn,norsdt,n701l5hy.try
<br />Jpplicr ror a pcrmir suhje(rs rhc lmlicrnr ro acirilpcmhyofnor mrdrha nvc hnndr.d dollars ($500)
<br />-1.
<br />n owtrcr ofthc F)pcny. or nry cnplorrcs wilh wtrgcs ar th.t s)k compcnsDrion. willdo rh. wrk uri rh..rtrruE is mr
<br />inr.ndcd or oflcrcd ftn slc (sr..704.,1. Bosituss and Irrufc*ions cod.: Thc Conr.ctols l-tcns ljw docs nor rnply b nno*ncr of
<br />rhc pmllcny rh. ttrihs o, inq,ows rhcmn. nl who dmr {ch slk hi'nsllf.t h$*lfor thmu8h hrs or hcr.sn cn,ployccs.
<br />ptulidcd lh,r su.h impmwEnls e mt imcndcd or olfeEt lor slc ,L l{Ne$r rlE hiklins or iqmitnrnr is sh wnh,n oro y.-
<br />ol cohrkrioG rhc Owrcr Bliklcr siu har rtr hldcn of rmlins rhd hE o. sh. did nor huild or in{,mw ihc tmtE ry f.r lhc purtFs of
<br />_1. r\owncr.lric pmp.ny, ancrrlusildlyconta.ring wnh li.ci*l.otrtrd.iorsr. con\rru.1rhc nrcr$r (Scc.70.1,,1, Bu\inrs\
<br />Fnlilqsi)n Codc: Thc Contrd.tr's Lic.trsc Lrw docs nor llply h .tr .s.cr .f l)lol'cny *ho blildso. idpR,Y.s rhcr..n.
<br />and who conlmcrsn such pmicls wirh a A,nrmcron s) licen{dpu^uunr ro rhe Cootrcttr s Li..n* bR)
<br />-l
<br />!mcxcmfl under Sctio
<br />-lhalcudwillmrinrain!CcnificarcofCon*
<br />roSeltlnsueforworl(cB.onp.nsaiion.aslmvidcdlorbySNtionlT00oarhc
<br />t ho. Codc. for lhc pcrformncc of lhc work for which lhc lermit h hrucd.
<br />< havc dd will tuiitlii anrkc( c.mp.nsarion truarq as icquini by S(riotr 1700 of rhe L€hor Codc, for rh. rsrofrncc or
<br />rlr qork tu. *[i.hrhir lrcnnn
<br />A.,eircc.
<br />.o'npcis on in\ur.ncc cMicr o'n llolty nuarbcr &l/
<br />\^,
<br />ZvreI'-
<br />7-%-1-O
<br />-t
<br />ccnifyrhrr in rhc Ii.rIornDncc ol rhc sotk fd *hich rhhl.rnir i! isiucd.l \h.lltror cnrtloy 8ny pcrsotr itr trn, nhikr
<br />$ b b..onr \rhid b rhc wtrrcn d np.nsarion la*s or crlitoiriu. and esrcc in ilIrh,uldt !,h{bi.dtollE
<br />"orkcr.orp.trsariotrptuvishnsoisccrio.l?fiioflhctitqC.dc.lshlll.tunh*irhconiplywnhrho$tmvisionsWARITIN(;: Frilur. r. *curc w.rkls compcnsatknr covcrige is unlo{(ul. utrd rhrll suhj.{r a..trDk,fr Io crimiMl pcmlrics and
<br />civil 6trcs up lo om hutrdrcd lhous{nd dollm (SlLxl.(x)0)- in uddiriu, t, rhc..r or.orFnsnlion- d.nEacs as prcvidcd r(tr rhc
<br />Scclion.10?6olrhcLltnrCodc.inrcrc\lrndtrtronrcy.lces
<br />Y,.,",t/zqlFI
<br />DECI,ANtrION
<br />Ihercnylmrnundcr pcnalryolFrjorrrhar I an lidn{d rndcr tbvisn orchrpts 9(commncin8 s irh Scdio. 7fir) or Divist,n l
<br />.i rhcBusim$ d PDltsion\ Codc- Md my liccns n in tu ll fo.ce dxi cffc.r
<br />q ,,."-,,,,-. 1733:5lc
<br />-."",-".,lttb*1,cr 1," e 1crcxf,,3 t R f^,r
<br />calirf,urJQN.LENDuc-dliEull
<br />Incrby arfirmlnder p.nllryorpcrjuryrhar rh.r. k a.on(flclirn lcndinS lgcrcy for th. Ilfformk ofrhc wo ror *hidhlhn lrmil is
<br />nsucd (ss 109?. civ c.).
<br />A.EPIICANI.IIECI,AAAUON
<br />Ilrrhyu innlDdcr pcnalry of pcrjury onc olrhc folk,*ins d6br ionsl
<br />Dcnrlilion PcmnlAst slos Notitication ltdcral Resublions ('lnt.10, Pan6)
<br />-Rcquncn
<br />Lcttcr of Norirt tbn
<br />_l.cdifyrh rhc rcdcralr.luhrions rSdding dsb.so\ r.m)vdlnrc kn rtdi.ablc ro lhis lmjar
<br />-l.cnifyrhd
<br />I ldvc rcod thnlpplicarionuntndc rlurrhcrh)vc infl,nx i{nr is.or..r r.EccrocoflrplywilhlllCiryud Counry
<br />ordinomcs.nd SIare L.ws rclarins ro buildins con(Dcrion- ond hcr.b, llrhtri7c tuprcscDr,tiv.s oil[h Cnr rtrd Cou.ryro cnr.r xF,nrh.
<br />rhnc nmriotrcd pr.p.ny rur insNcr
<br />>pplcnnl or Asent
<br />\-'l* *-"rn.i {
<br />,.,",ek*liL
<br />Set Backs
<br />Fo rm s/Stee l/H o ldown s
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVlnsuiation
<br />Roof Sheathinq 't/0/t^;tffi
<br />Shear Wall
<br />Framing
<br />lns u lation/E ne roy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req \
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL 1
<br />Certificate ol Occu n
<br />Notes Remarks Etc
<br />]Ia!$i8[1;!]!tutNsa.IlaN
<br />lEl;I"Anr[UN
<br />I h.rchy alllrmundcr lEnllryofp.rjuryo't oilh. n,llo*in8 d$larari,r:
<br />I
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