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BUILDING. INSPECTOR BECORD
<br />SITE-WORK DATE ONNEI( BUII,DER DEI,CARATION
<br />I hcrchy aflin uid.r pctrrlryof|.rltrrv lhar I.nrcrctrU liun rhc Conlrrct8 l.iccn\c l.as nn rhc r(nkiwnr3 rcison (Scc70:11.5
<br />Busnr$ .trd Proltssior Codc) Any Ciry or (in'nry which rcrluircs J ff,n ir h otriru.r. arlcr, nnr)vc. dcN)lish or rP& !n,
<br />{rudurc. nri{,t' irr ilsumcc. rl\o rcqutc\ rhc aprlird nn \kh Frnnr ro rllc. \i8trcd {rrcrmtrl rhll hcor shc i\ lir.n\.d N.urtrr
<br />to rh. pmvnr,i\ of rlr Cotrrrrclor's l-iccnscd ln* ((h0tlcr 9. (innmcrci'rg wirh Secrn)n 7ffX) of Divisn 3ollhchrinc$itrd
<br />!rolt$ion{Codc) orrhrr hcorshc hcrc'npr rhcrulionand rhc br\i\ fu rhc illcgud crcnUi()n Any violnri{n, of sdi Tl):l| 5brrtry
<br />rpplicrnr ro r Frmir \rhjrrs rh. {tli.r t)r.ivilpcnrlryofn.rftncihaniirchundrcd ollrn(S51X))
<br />l..r o*lrcr.lrhcrrorEny. or mycnrloycc\ lilhwngcsas lh.n {nc cotr1tL srn,n. witldo rhc work nnd ltE (Brur. n ior
<br />i,ncfrlcJ .rolltrcd a,n {Lrsd Tl}l4. ausii.\sr d Pnna$i.ns clrdd Thc (-o rrcloas l.ic.nsc l-n(doc\norQPlyroatro{ncrof
<br />ihcl )tf,dy *ho huilds or i'npror$ rhcGnr n whodocssochwnkhi'n\clrorhctsclforrhnuAhhisorluoq.c lnloyccs.
<br />,rtuv nlcrt rhrr {L_h Nprcrnrtrh m 'x, i' oxl(l or orlar.d lff sL ll hrwNtr. rh( huik,ing or impNkmd n q,*l *irhin
<br />'
<br />ac }\rr
<br />of.oplclidrrlrOwmrBuiltlcrwillhr$lhchurd.nolpmvir8lhJh.o!\hcdid n t{il] .r i'rll]turt rhc Pm|cny lnr tlf l]!q$* dl
<br />l,,sowncr.rrhc lW pcdy.0m.rclunlcryco.rnrlins $irh licctrrd conrrrctr\ t, &n{tu.r rh. ni()icd (Scc 704.i, Bu\i'it\
<br />and l,rdtsion Codc:'Ihc Co ntNrois Li.cis. l-rs doN not dptlyb dtro*ncr ol propcnywh(' huildr or impmrcs rhcrcon.
<br />and whu.otrrhcrsaor$Ehtmjccrssith.Co m.ld 9 licc,Nd puruor b rhc cont ktrsLi.ensltrsJ.
<br />I m cxcnrtr !ndcr sccri,r
<br />Dalc O*n.r:wonxris irirlrlslrslnon
<br />DECIA.E{TUN
<br />I hcrehy alftr undcr pcnalryofIc jury o.c orrhc tollowins d..lararnnN:
<br />-l
<br />hrlc rnd will m nlrin . Ccnifrllc or C{,nrnr ro Sclfinsu'. fd sorkc^- cn oDenso I ion. rs pDvidcd tn by Sc.rio.17(v!r oflhe
<br />tib.r c.d.. ror rh. pdfoflMr.c oi lhc Bork for which rhc pcrmil is issled
<br />rhrs p.rnril is rsud My$orkcrr c.n,0.nsrri(r, i'isrrrtr.. triilcr d Fni.y nnr$.r ar.
<br />ar,.r"*.*r-$rulR^)<.ori c\ Oa-o ,,.r,,", I l.l.pt
<br />I ccnifyrhnr i.rhc ldrfornrNcol lhc woll li! whi.hrhis pcflnit is i\su.d.l shrll nor c Dk,yrny!c otr in atryrunncr
<br />s $ n, hconE subr{r ro rhc sorkc!( conpcnslrion hsr of Califomir, a0d .grc rhd 1r I should tEcom ubid tu rlr
<br />sorkc^' cornpcns0l ion povi\ion\ ot S$iion ]?m of rhc ttrbor Grlc. I \hrll. ron hwirh c.nln], Nirh ih){ Pn,vhbn\
<br />WARNIN(; Frilurc b slrur. workcr{ .onlicnsnlion covcm8c ic unh*ful, md shrll $rbic.r .. cDDlo}tr ro si'ninrl pctulri.t trid
<br />civil fincs trtr lo onc hundrcd lhou\ann dolla^ (51(x).(xn). ir srltliri,nr t, rhc doi ol compcnsurion. danugcs at ftuvid.d nn ttu
<br />Scd rf l07a ulrhc LthtrC.(lc. inr.cn rnl ({!ry \ r..\
<br />Dr..:4.az.Yt
<br />^eetiaat
<br />DECI.ABAIIAN
<br />I hrrcny a,ltr undci pcnrlry ol Frjury rh,r I d liccied xndcr pr.vish olCh0lrfl 9(contrrcncins siri s.crbn 7filo) ol oivision.l
<br />.r rhc axsnrs rnd Pmfcsions Codc. and mylicctrse k in lnll fore and cffc.r
<br />B,10q.
<br />,"" '1-:1-.yz v^
<br />CANIIAIEI]QIIDIDINIj.LGENCI
<br />I hcrchyofilirnuM$ Jrn tyol'|rjurylhdrhcrcisumn{todt,n[ndin8ns.myli{rhclcrlorronceofrhcworkforshichrhisDcr.riiis
<br />hiurd (Sc. 109?. Civ C ).
<br />AITUCAN[I2ECLABIIION
<br />I r.RiyrRinru cr ltmlly olpc.jury om olrhc trlo*irs dclmrionr
<br />Dcnr,lirn,n P.nnirs sbc{os Noriiicrli0 Fidcral RcEulrniqN ('liilc 40. Prd6)
<br />RrqLrrd lrrrcr ol Norifiriiotr
<br />l.cniryrh.trhclidcmlEsulali('nsrcsudinssshc\l.{rcnmvrlucnornppli.nhLrolhntroi.tr.
<br />-E\itnify rh,r I ha,e rcad thi rmlicdrnnr d (rrcrh,r rhcabovc irronndion is cotrccr Iulrccr.comPlywirhallcilyondCounry
<br />o ir.nccs and Shrc t-assEl(itr8 h}riklin!.ohnd.ri( , aM h$ch
<br />*.\c nrrlotrcd php.ny lor NI
<br />A;-
<br />{nrarivcsofrhisCny,nd Counly lo calcr u!.n lh.
<br />4 .-t tol)sl. e' I 6
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framing 'l/Coz*sbQk
<br />lnsu lation/Energy
<br />Drywall
<br />Brown Coat
<br />lt/asonry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL
<br />"/Lt
<br />/tt >L a6
<br />Certilicate of Occupancy
<br />Notes, Remarks, Etc
<br />ID/SIG.COMMENTS
<br />I cr,l.r'. \r,tr.
<br />Forms/Steel/Holdowns
<br />Ext./lnt. Lath
<br />T-Bar
<br />Flood Zone Ceftif .
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