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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUII,DER DELCARNTION
<br />I hcrcby rlltm undcr pcnalry orFrjrry rh,! I m.rcnu t m rhc contrcloF LiccnE &w l'or rhc lollo$ins rcnsn (s..70:rl5
<br />Bu\in.\\ nnd Prof.sshn Cod.): Any Ciiy or County which rcqun s o lEmil lo con\lrucr- alr.r- ifrpror., dcfrnith t{ rcJun,3iy
<br />slrudurc, lrior to ns nsuarcc. also rcquircs rhc lp,,licanr foi such Fmi xr fiL a li8ncd sdr.mnr rhar lf, or shc G li(cn\cd l)U^uanr
<br />k, rhc nmlisn,ns of rlr Comrrrrofs Liccn\cd hw (Chrlr$ 9. C.nrnrking wilh Sccrn,n 7(XD oi Divirn,n .l ofrhc Businc$ ond
<br />Pturcsii,)nl Codc) or ihd h.orshc iscrcnr lncrL'nonmd lnc bash rbr lhc ullcscd cxcnTri{'n Aty violariotrofSdion?0ll5hyany
<br />rrpli.a.t lor a p.nnii suhjarsthc ryllicanr lo !civilrcnrllyol nolarrcth,n fivc hundrcddolltrB($soo).
<br />_l- a\ own.r oi rhc poFny, rr my c lpk,yd\ sirh wascl r\ rh.n \rb .o'npcnlar ion. aill do lhc wo* $d rtE srrucrr. is tror
<br />dd &l or .fro cd for qlc ( Se.7t!-4. Businc$ and Pnic$ions Codc: l hc Conrracrors l-iccn* Uw doc\ n.r rtPly k) atr owtrq of
<br />rhcptupcny $ho tdilds or inqft\rs rhcdr. ari who dc\ \kh so* hi'nelfor hc.scllor thou8h hh or hc, o*ncnDk'ycc\,
<br />providcd rhar such imDn*cnrnh m mr inrcnlql ofcrcd lor $lc Ii houcvcr. lhc hoik]ing or imlrl,rc,mnr is $ld sirhin oN JtJr
<br />ofcomDhri'n. rhc O{rcr Builds wilih.tr rhc hurdcn ol povine rMr h. or \i. did
<br />'xn
<br />build or inl,ovc rhc pmp.i, ftr rhc N{b{ ol
<br />_l-aso$n,ofrhcprop.ny.anrcrclusilcly.ont i'r! sirh 1i..trlcd.onr..krsn).on(rucl lhc p()jccl(Stc 7044. Bu\irrcit
<br />rtrd ftlfl\sir Cod.: Thc Cnnkadois Licctr{c L{w dc\ mr nptly ro in o*ncr olpi,,pcny who buildr.r nn,rrolcs rhcrc.n.
<br />and who conrnd\nrsuchri{,j.drsirhrConr .bn,li.c.{d pur\Mnr ro rhc Conlm.rols Liccnr lrw)
<br />-l
<br />rcxcnrpr u crSccr
<br />(rxner
<br />lll)BtrIiEllraufl,NsaxllN
<br />U!.CI,A3AIION
<br />I hcBhy rltnn undcr pcnilr, or Fjury onc orrh.lnlk,wiry dcclrrrrn,n\
<br />-lhrvc
<br />rbd villnrinrain a Ccdiararc oiconrenr ro Scll lnsurc t]rro c^ .omr.nsdn,., rs pmvidcdforhySccrionST00oflhc
<br />ub.r codc. ror rhc p.rromncc of lhc wo* for whth I hc pcnnir L\ issucd
<br />I havc ind qLllnmi rin workers .onrFns,rtn, i',\urrn.c. !s rcquncd hys..r n l?(x).frhc LrhorCodc. tu. rhc Ii.rnmuncc.t
<br />rhc \ork hr which rhis pcnnir is nsLrd. M y sor*cn co'nF.slrion in\!rrn( .di, dd Fni.y trutbd &c
<br />I ccdilyrh,r i.rh. p.rlornmmcoflhc wo whichlhn Dcnni k nsucd.l fiall n.r cmpk,yrnyr.r$n in otrynunmr
<br />\o s ro bccomc slbrcd ro rhc wnkcs' coDpcnerion l.Ns or Cllirunir .id iSec rrd il I should bcoN sut jsr h rh.
<br />workeis' comocn\ar ion pDvhn,ns of Sc.r i.n l70O oa rhc htitr Gd.. I $a11. Lnhwnh !_onDly witn lhF pnvi\nnn
<br />WARNINC Ihihrc lo *c!rc workcn' c.ml.nsdion c.vcE8c ir uih*ful. nnd shrll suhj<r cDDloycr h oinritul ,cmhtu\ rnd
<br />civil Inrcs up ro onc hundrcd lnouslld dollus (llm.fll)), in addirn,i tu rhc..N oi con{'ensalion. duEscs !r pn,vid.d r(r rtu
<br />SLrrion 1076 olih.l-itnr Codc. inrcFi af,d artnmv r fcc\
<br />s/zqlt{ App.6tr,: R"on P.ogr/;.
<br />r t('F\it.D(0NlR tt(rR ,
<br />DICLAAAIION
<br />I hcrci,y !m!nlnder Dcnalryorp.Duiy rhar I am li.cnscd xndcr pmvnion ofchoflq 9 (onnmncins wirh sc.rk n 7m0) olDivhion:l
<br />oi lhc Btrsircss,nd Profc$ions C{dc, !trd 6r liccnsc is in flllfor.! Md cffc.r.
<br />r-ic"o.c cr,*, 6 l.i.cn\c Nnnrhcr aoYlrl
<br />5/zt/ t(a/o 4 E orat, /,'zS
<br />coNirBucu0NraDlltiAlil;!(I
<br />, h.rby dfiinn undcr Fnrty of pcljury lhal th.rc is a consrrucrbn lcodin! agcncy ror th. Frlbrmrcc of rhc *ork nr whi.h rhh pcmi lc
<br />ksucd (Scc. 1097. Civ C.)
<br />L.ndcj' Namc
<br />-
<br />A.PEILCANLIEEIAIAIIAN
<br />l[al.ty riimuBlcr pcn,hyorFrj.r! otrc ot {hd rolbwnrg d..hruriotrs:
<br />lxmliri.n Pcflnils.Asbcsros Norificrriui F.dfial tu!!larions (Tirl. 40. Pd6)
<br />-Rcquncd
<br />Lcrlcr oa Nolificarion
<br />I ccnilyrhxr rhc fcdrtul rcguhrnnr\ tuganli,r! i{ks{o\ icnn rl !r c trorrpnli.3hl. k) rhis p(ic(r
<br />l.cnilirhnr lh0vc rciil rhir atpli.rrion md srtrrcrhrr rhcrtx,v. inf(rnrrnr (..rc.t I .8re nr comply *irh trllCiryrndC.udry
<br />ordiMn.cs.nd srdc Li{s rclarin8 nr buildinsbii cri{'n.odhcrcby,urh.rizcr.l)icrnlnrivcsotrhi\Cilya(lCoonr,kr.nr.ruB,nrh.
<br />rlxrr nf,driinr l,'ot)c'r! ttr irND.(rionttr
<br />Applicnnl or AAcnl SiEtrolurc
<br />,"*u*", "ron.t,E2o 4-</rt
<br />*,., 5/2q18
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Venl/lnsulation
<br />Roof Sheathinq
<br />Shear Wall \
<br />Framing b-!t- tg )-0src#f'il
<br />lnsu lation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />,,^
<br />FINAL -7 -,1-t?N,\t-li))
<br />Certif icate ol Occupancy
<br />Notes, Remarks, Etc
<br />Erection Pads
<br />Flood Zone Certif .
<br />I
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