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BUILDING. INSPECTOH RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS oWNER BUII,DER DELCARATION
<br />I hcrcby o,ftm undcr pcmlly ol Friury rhal I dn crcmfl fn h lh. CuntrNttra Li.cns. trw nn ric following rc.sn (Scc70ll5
<br />Busincs and Protesbn Codc): Any Ciry or Counly qhich rcqutcs . Fcnnir to conslnrct. illcr. in[m]c. dcmolnh or rcI'.n nny .sd.rur. pri{n b nl t\Mee, aho rdqunc! rhc,rpliclnr lor slch Ermir ro filcr si8n d starcftnr rhar heor \hc n licci*d f,o*uanr
<br />t' lh. provnioDs oi lhc Conlflclols Li.cnkd tjw (Ch.prcr 9, Conrmcmine wirh Su.lion TtXXr of Divisbn I ol lhc ausn.$ rnd
<br />PhLsskrN Codc ) .r rhar hc orshc isdrc'npi rhcrctro'nrtrd rhc brsis li,rihc (llc8cdcicnrlrii{nr Aryvn,hti,nofSeri'n7O.ll5hyany
<br />al)Pliclnlr'orrll.rmiisuhj(Isrhenpllicinrto.civrlpcnrlryorn.rrorcrhM,lvchundrcddollan(s5(D)
<br />l. N owitr ol rh. pn,pcnt. or nty cmpk,Fc\ *irh *ngc\ a\ rhcir $lc conrli.nslri{)n. will do rhc } ork rxl rhc nturrc is tror
<br />inrcn<lcd or oficr.d f(, $lc iSN 7(84, Busircss rid Prof.\snrn\ Cdl.: Thc Conti.rtr \ Ltcn\c bw do.r nor q,tly ro r..snd of
<br />rh. lnrrit! Nho hilds or i'qm$ rh.Nn. $d *lt) des ssh wo* hnnseli.r h{i$lfor rnrou8h hh.t hcr own cnrployccs.
<br />prov cd rhrr s!.h i |,orcrrcnr ! n.r i .ndcd.' olld.{ tur elc ll lt$cvcr. rhc huildin8 ,r i'nnmvcNtrr i\n,U wirh'nnnc trrr
<br />of@mplcri{nl ih. Owncr Bui d *ill lurc rlE buri.n ol provnrs tlr lr ur sh{ dil nor build or inrpo!. rhc pnFiy litr rhc puqn{ ol
<br />-l-
<br />a\ owrcr ol'thc ,,rcIlcrly, rmcx.lusivclyconto.rine wnh li..n$cd.o.r,croN ro c.nndd rlt pmid (Scc.7ol,l. Businc$
<br />Md Pn,r6\bi Codc thc CoirE.ktr s l-icense ljw docs not apply to un owrcr of Dmp.rly who 6u ilds or inrpoves thcrcon.
<br />and who o.tncls lor su.h J)rojNk wirh a C. aco(s) liccnscd puruxhi i, rhc G,dra.l.as t-t{n* tjw)
<br />I rm.xcu.r un.l.r S..r
<br />]IOAKI&!:CAUIINS ]IoN
<br />DECLAMIIOX
<br />I h.rd,yrlTi' rutrdrrI,.Mlryolpcrjuryomolrhc&lh*irsdc.lirnri.n\
<br />-l
<br />havc ud *illnuinrain !CeniaE.rcotConscnlr. Scllltr\urc rd workcn' co,npcnsariN. as Im\ idcd lorhyScclion.lT(i)oirhc
<br />L.bor (-odc. io. llr ld.rnrnc. of rhc Nork forshi.h rh. pcnnir ir isiurd
<br />tr\c^ cotrrpcn\rri,{ iD{mn.c cx
<br />6 -c {q
<br />-\l (n'ry rhr m rhc Frr'trnrricc ',frhc *, rk f'tr shrh thi\ pcrnrir is t\ucd.I \hrll nor rnrpl.y rny p.r{,n in dny mMn$
<br />$ sbhc!!m shjNr lo rh. worlcn .oDlPcnsd ior lnwsorcrlifonrr. d +Rrhd ilI should tE$m suhrl krlhc
<br />*orkcrl c. rFtrslrionpornion\oiScdionl7(Xlofrlr Lrb.r Crodc.I shrll. lonhwirh conDly with rho*rrovsnn[.
<br />WARNIN(;: Erilurc r. ..nrc *.rkcrs (nnp.i\alion covcugc is !ih*tul, anJ rhall srhii rn cn1Pl.Jd ro.rnnin l Ftr.lrics.nd
<br />civil firc{ up b oflc huMrel rhousrtrd dollrs (Sl($.tXXr, in addirhn k, rhc..n of.omFnsdnrn. drnDgcr as fioviddl for rhc
<br /><F,ri.n !r"6..rh, r.,ho-.nir. I _
<br />,.," \r- t1- l( n,,,,.",, dXVt{oohC\O\
<br />Lr(!.NsF!, (]uN rRkl(rR
<br />IIEIIA8AIION
<br />I hcrchy lfii,nrndcr pcn lryoft$juryrhrr I rtr,liccn\cd undrr pnivisi{n of (-h3Icr 9ico nRncing *irh Scrrn,n TlXX)r ofDivnui l
<br />.r rhc Busin.s rrl Pnni$i.ns Oxlc- md nr,li.c \c is ln tulltur.c nlcrlt.lD
<br />Liemcch$: \) Li.cnsc Numbcr 6ea-qo"r
<br />CONJIIBIJSIIONIENDINCIIiENCI
<br />I lf,rht rffirmrndcr pcnrllt Dfp.rjury rhat rh.rc t a con(rucrion lcndi',3 r8cnc, fff rhc pcrfontrcc olrhc qurk for trhi.h rhi\ If,nnir i\
<br />i\ur tscc .109?. Civ C )
<br />AIIIICANTDIEIII&UrcN
<br />I rr($r rrfin rndcr pcnahy ol pc,jrry oE ol tl,c r'ollowinr dcclnratn,ns:
<br />Dcnnnirion Pcrmih Ashcstos Norificarion fcdcGl Rc8uhtions (litlc40. P!n6)
<br />-Rcquncd
<br />krrer ol Norifi clrion
<br />l.cniryrhrrrhc fcd.nlrrsulrri,)tr\ rugnrdi',8 r\h.(o\ r.nxrrlrrc nrrrptlicrl,lr r) rhn I'o !
<br />_lccnifrrhor lhrvc rcadrhh 0lrlicnrhn ml stnt. rh0r rhc *{'c irLnMtion h comcr l!B,srocomolywirhallCiryandCounry
<br />ordinlnccs lnd Stlrc tr*s EtalitrS lo buildins co.(rucrb.. on hcrct yaulhorizc rc|{crnrativcs {,lrhn Ciry.nd Couf,ry k,.nicr ulx,o ihc
<br />GIR- r(
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/Vent/lnsu lation
<br />Roof Sheathin s
<br />Shear Wall
<br />Framing ,)
<br />lns u latio n/E ne rqy ';- lr*lt
<br />Drywall
<br />Brown Coal
<br />l\4asonry
<br />Pool Fence
<br />T-Bar
<br />tlandicap Req.
<br />De puty Final Beport
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL 1-7"t8 Dr.Vlrt,
<br />Certificate ol Occu pancy
<br />Forms/Sleel/Holdowns
<br />*,td-Ycl
<br />Ext./lnt. Lath
<br />/2\
<br />Notes, Remarks, Etc.
<br />lfl:.]1 . \:,1'...
<br />J,;";::ffi-"::-_ \----l
<br />Pemi,E*me,pn ,: \otl+ trs-qa -
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