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BUILDING. INSPECTOR RECORD
<br />SITE.WORK ID/SIG.COMMENTS OWNER BUILDER D8L(NRATION
<br />I hcrchy rltrm ufticr pcnllty,n p.rjury rhrr I!mcrcmpr riom rhc (i'nrrartlF Liccn\c L.w tulhc l;lklwios ran,n (Stc7lr.rl5
<br />Au'N\\ MJ Porl*i,'n C(xL): Any Ciry oi C,'unry whirh rcquE\ r Frmir n) c.nntucr. al(cr, ,mpnr, Jctul$h o, Epir ary
<br />slfl'crurc. prktr Ii rts ssuancc, llso nqur.s (hc rtnlrn nn \u.h ttnnf n] lilc i nSncd (dtcmtrl rhll heor she r lEcnd pontranr
<br />l') rh. ,lr)vrn)ni .l rtf,. Conra.(x i l-EnrcJ tlw (Chlpr.r 9. ComnM.rnA w h S(ton ?00(} oa Divrbn :l ol rhc llurincs lnJ
<br />Pn,li$rrsC,rlc)orlhirhcorshcisctcnu'rth.rclbm n th. hlsir n lhcalLredcrcmprn,n.Anyvi,,lnrionofSctinTo:tl5hyrny
<br />lml(anrlnr ar.rm iuhjcrkrhc.ttl'canrk,r(,vilpcmlryolnorfrtrcrh,nhvchunJrJddur\($5m)
<br />l, rs orkr nlrh. pn',rny. or my employccs wnh wr8.( !\ rhcn $l!. .lnnltnrdri,'n, w ldo rlE *)rt.nd rlE duh tr nor
<br />hr.nJ.d oro,l.Ed ln. {h (S!r 7(X-,1. Burm:s r,l Pnnis$on\ Ctilc:'lh. (i,ntrkr'\ l-tcns l-r* Jocs frI amly k, an orncrof
<br />rhc pn'pcdy whohr s .r impn,rcs thcE,n. rd *fu) 'nxs \urh ufi hrnr.ll or hcr.ll.r rhoueh hn or hcr own cmfloy..s.
<br />nrov"lcJ rhrr srh im|n,vcmnk !E rr, Ncnhd d dlieK{ lor slL lt. ln,wcrci rhc hurldmg or imDn)vcnrnr s {,Ll withm onc Fr .
<br />ol conlPLrir, rh. O*ft Bu dcr wII hnv. tlk tmnln .f pn,ving rhd hc or \hc drl Rn b{&l dr mpsh lJr. Imtlily ttr thc purll's of
<br />L r\owtrfiolrhc Pn,F..ny, rncrrlunv.ly(onkrcrnS wih h.n\.!i roturn,s k) con(rucr ih. ttu.d (sc(. 7044, Buqn.$
<br />anl th,rlsrnrCodc: IhcContrrrtrsl-i.cn\cl,,wd.csndl.nrlykr!n wncr.inn,F-nywhohnrllsorinnrcvcsrh.rcon.
<br />aDd wt!' conh(B ntr nkh 8,j&r( wi h r conkr(,(\ ) li..ns.d purrrr h rh. cnnkr.ktr'l Licc rL1*)
<br />I rnrr\cnln tr dcr sc.rlu .B &PC ntrrhAr.r(fi
<br />.UAAtrIAE:CAUTENIAIIA!
<br />DEQAAAIION
<br />I hcrchy al'ltm und.! p.nally oi pcljury om oirhe,nu{wr2 deludrio.\:
<br />-lhavedrwillm(int{nrCcnili.llcof(i)nscnri',sclt.lr$urcntrworkcr'.ompensarion.a!rrorklc'llnr$ySc.rn,n.l70odlrh.L.txn aillc, ntrthcFrfornrnccolrhc w,* Ltr*hrchrhc p.rm RtnRl.
<br />I havc ann will mlmra wnrkcrr .ompcnsdrnln insur.nce. is rc{ue{ hy Sell)n .1700 oi rhe lil[r O)Jc, in rh. p.dnm^-c or
<br />rhc lorl n)rwhrchlhh pemit is n\uc'i Myworkcrs u.mrrcn\anon msuraE-.c.ntl aBl E,liy nunber&:
<br />3 -1"- (7
<br />I ucdilyrh(r inrhc tl(rldrronc.ofrhc work I', whrhrhis p.rmn 6 r{u.J.l rhrll nor cmpl,yrnypcBon in anymnncr
<br />$ r\ t' hraom suhF-rr, rhe *('rlcn ronpcn\rr('n h\a ol Crlili)mia. rnJ4Er rhrr 'fl sh,uu lrcoft \uhj..r tu rlE
<br />work..' ronFn$! i,'n p('!'son\ ol S.cr u, .t7(Xl ol rhc uhtr C,xlc. I \h3ll n'nhwirh (n'ntly w,rh rh,{ FJv,nonr.
<br />WARNINGT Fr'lur t) {cnic *ukcs' comFnsrr(,r
<br />.ivrl lincs u! l. n. hutuircd lhnRMJ Lrollffs (Sl0o
<br />. '\ unhwlirl. lnd $!ll NhF_l rn enrploycr 1,,ominrlllcn trc\,nJ
<br />DlrrFrrrtr,. d.'nL!c! r\ nn,v'J.'i ntr rl'r
<br />DECLAf,ATION
<br />I hcEhy a8trm und.r,x.ahy or p.rjury rh.t I ah li.!n{d undr l)n)v(n)n drCh,prcr 9 (onmmihf with Satbn ?000) olDirntr.l
<br />of rh. Buiitu\s ail Pmfd$nths Cod., ,Jrl ny k.n\. is in tull nra aBl .llcrr
<br />/A /tal-:7 - 1
<br />gIIIEIBIJSIAN-IEBDIIC.AAENCI
<br />I h.rhy allirm undc! IEoalryof p.rjury rhrr rhcrc n ! uon(rutri,n lcnline rgefry lir rhe perfolrrrlm. of rhc w)rk tur qhich rhN ltrmn r
<br />trsueil(Se llD?,Civ. C )
<br />APPLICANT DECLARATION
<br />I trrchy alim under Fnahyolperjury onc oirhc nnb*in8 dcul.,!lions:
<br />O.frnntun Pc.mits-Ash.(.s Not i.alion Fclcrll Rc8uhtions rTnb40, Pd6)
<br />Rcqurcd t.lrcrot MnilMthh
<br />_I crd,lyrhrr rhc lc'lcrrl rugulJrnr\ rlr'ltrrg r\h.(o\ r.nx,yrlm or rptl'uhh n) rhA l,rt)jd
<br />nll]ly wIh ill Ciry rn,l (',,unrr_
<br />Cny anJ Cotrdyt' cnr.r ut'n rlronlfl.!tr.\ itrJ Sr.(.I-r$\r.lI '! t)h.r.by rtrrlutrc rcprcscnlrhv.s of rhF
<br />rh'vr n{nr()n.tl nr)I.nt lnr
<br />,\D li.: l orA!.nl Sirnrlurt.(
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Roof Sheathing
<br />Shear Wall
<br />Framin s
<br />lnsulation/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 />Flood Zone Certif .
<br />FINAL /-7lt 7
<br />^7cz-Certilicate of Occupancy
<br />Notes Remarks. Etc.
<br />47-t
<br />DATE
<br />Subf loor/VenVlnsu lation
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