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BUILDING. INSPECTOR RECORD
<br />SITE-WORK ID/SIG"COMMENTS OWNI:R BUN-DER DELCARATION
<br />I hcr.by afinn undcr pctr.lry of perury rhar I am crcn' lnrn rhc G)nrrrcnrr LrcDsc tiw ror rhc ftnbwing rcosn (Scc?o.ll5
<br />Busincs\ lnd Pnntsn$ Cod.)r Any Ciry ot Counly *hkh rcquncs I Frmir ro con{tucr. rli&. inrtnnc dc'ft'li{h or rc!0t rnv
<br />sdcrurc,lriix ro irs issu.ncc,6ln, r.qun \ rh. $pli.anr for su.h pctmir b lilc a sigrtd stdrcnEnl rhrr lf,.r \hc is liccn\cd plrtanr
<br />ln rhc proli\ion\ oirhd c.nrrn lois Liccnscd lrs (Chrnid 9. com crcirs tirh sccri( 7lxxr or Divhnrn I 'flh' Btrri'r's rnn
<br />Pmrc$i{nr\ Codc ) .r rhrl hcorshe i\cicnr,rrhcrciiomand rhc bnsrs Ior rhcrllcg.dcr.'nflion Anyviolirion.lscdionT0ll5hrJnv
<br />,nplicrtrr lor rFrmir sunicrsrhe appli.ad ro rdilpcnrl,., ml nnncrhin fivc hundtcd dollr (S5mr.
<br />-1.!\o*ncrorrhProtEny.ornryctrPhyccrsirhwrscsisrhctsoleconrPensnrioi.uilldorhetrorkrnlrh.efl(turchmrinrcnded .r ofcrcd itr lrlc ( ss 7(lr{ Bu(incs md ltofcsiotrr Cde, l hc Grtriois Licctrt ljq doc\ trot iodv ro ri .wncr .l
<br />rhcpmllcny *hl build\ or nlltm\$ llErNn. od sho doc\ surh work hiNcli or hcr*lf.r rhmu8h hi or hcr o*n c tployccs.
<br />Dmlnicd rh \uch inurownrns m ior inr. d.{ .i .fi.td lor $h ll lx,srkr. rtt hlrildiu or iqrorcnxnr i\ q,kl wilhin nm Jt'tr
<br />ofconrrbri)n. rlE Ou'nq lluikhr willhdvc df, buklcnorDovinsrttrrhcorshc did rt buikl .t inrlmw rlk PmPCn, tu rh! l[rIn{ ol
<br />L ds.wnoofrhc prolEny. uncx.lu\ivcly..Dr.dirr8 eilh liccDscd onh.hn ro consl'lcr rhc ,nrid lsec 70:14 Buiross
<br />and krldsion Codc rhc Contrdois l-icctrsc l-r*(locs nor nmlyro itrorncro{pron !whohuildsorn.!ft,vcsrh.icon.
<br />ond who co ncG aor skh rnrj.d s qith 1 G)nrm.lo(s ) li.cntd Pu u.hrrorhcConrtacktsLi.cnscLrw)
<br />.B &PC.rorrhhrrrn
<br />Drle o*n€r
<br />lvoRxrlrs' (loliiCNsl l It lN
<br />D}:CLA.BAIIQ!
<br />I hcrchy!tlirDund.r lc rlryof PcUUryoncolrhc tulk,$in8dccltfurtnrs:
<br />-lhlvcud!ill'minrr
<br />rCcnificiicol'Conscfrni Scl| ln\urcld s.r*cs conrnrtrsrn,n..s pn,vidcdnnhyS..rion.17(xl.trhc
<br />htrtr C.dc.lor rhc pcrrordan.. orrhc worl lor *hich rhc pomn i\ hsu.d.
<br />r r i\ rsuc,l Ni,\nk.rr corI{n\rrtrtri trr{rrr\'.r'ric' rxll\,lielnnorhcrrtu':
<br />c I
<br />to o,oe.J.4
<br />I .rniry rh.r ir rhc I'crioflutr.c .f rlr soik for qhich rhir Ei,ni( i\ i\\ucd. I shill nol cnUloy rn, l.non in rn, nlndcr
<br />*r.\bh.comc )l(ln,rhcsorkcrsc.,Pcn\ariolawsofcrliLiltir.dDdrAr.crhriiflsin,uldhcconrrul,Jecrhiht
<br />$oricF c.nrncnsarionpn,vi{otrsolSccrior:r?(x)oirh.lrhtr(ixL.I{hrllbdhrirh..lt)lt*irhrho{pdvi\n)ns
<br />IYARNING: lrailr. t, sdr. workcr' c.nrFn\lrion c.vc'rgc i\ rnl wtul. {nd sh ll {'hjccr ur c rdoFr ro.rnnitul NtrihEs xnd
<br />civil lirci !n b oic hundrcd rhou\nnd dollar\ ltlul.(Xx
<br />Sccrn,n:1076oirhc hhir a.dc. i.lc.ci rtrd rrtnrf,r'\ rcr\
<br />)). i', xddirof n' n'. ro( fl L'danusc\ nr fl,vntd ntr rnc
<br />).(: t A-n
<br />DECLABADAN
<br />I hcrby.fiirm u.dcr ncnahyofp.rjxry rh.r I .,n liensn urdcr l)n,!hio. oiChlPlcr 9 (comm..i.8 wilh Sdion ?O0O) ol Divhion.l
<br />of rh Bulincssatrd Pmlcssnnr C.dt. Md nry liccne is in tull t'orcc lrxr cfic.l
<br />T",85i ."-.--'
<br />toao/?47
<br />c()NslRuc'fIoN I ITNDIN(| ,r(;tNCY
<br />n{icJ rsr 1097. Cr\ C i
<br />I dtrdris Addrc$
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<br />APPi.ICANT DECI.ARATrcN
<br />I llrrby l1lhn lndd pctr.lly olpcrjrry otr..lrhc followir8 dcclarlrion\:
<br />Dcmlirion Pcrnrih Aslrslos Notincarior F.dc.alR.lulari $ (Iitlc .10. l'!n6 r
<br />_Rcqtrncd k(cr of Noriicolhn
<br />I ccniiythot lhe icd.rar tsuln(ions rcsanlins nsbcno\ rcnmval rrc nor.I|rli.!hlc t' rhkrn)j€l
<br />l..rrrly rlrN t h.,rc,.ltl th\ qi0lr)ri1) 'rnl,xi..\ rnl Srn. l-r\\ r'liri'r! r, l,tri1,1tr,9.(
<br />I asrcc rn onrpl, wirh nllCiry!trd Counr!
<br />ri|R\crhlne\.lrlris ( iiyrid ((iunryk, cnr.r uFnrla
<br />{tnNr nrcnriomd p!,l[nt tu in\Fcrion
<br />,\ppliconl or Aa.nt Si,lnrlor€
<br />9n"t )r/L Lc /c
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq 't //t //c ?>ab
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lvlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL /0/ [*/rr I Dqv
<br />Certificate of Occupancv
<br />Notes, Remarks, Etc.
<br />DATE
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