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BUILDING. INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS OWNER BUILDDI' DEL(ARATIoN
<br />I hcrcby iflir r xnd.r Fnalrr,,fpcluiy rhar I Jn dcnrpr lrom rhc Conrracnns l,iccnsc lrw lor rhc folb*i g r.r$n (SLr.7oll 5
<br />Businc$ .nd Pmicsion Codc): Atry Cily or Coutrly whi.h r.qui'cr i ,.nnil ro c.trnrucr. alt$, imtl'ove. dc'nolish nr rcnrn Jny
<br />nrucr$.. prior lo ns is\uancc. also Equtcs rhc aarlicrnr rbr such pclmil h nb r si8rcd (arcmnl rhor hco, ihc is liccnrd Nrsurnr
<br />lo lhc Eovnions of E Co.ki.ror's Licctrscd hw (chapro 9, Conn.n.^inB wirh Scclion ?0(D oa Divnion 3 oflhc Busnr$ and
<br />Pmtcsn,ns Codc)orth(l hcorrhc iscicrlpl lhcrearonrolld lhcldsh trtr lhc ollc3cd cicmflion AtryriolarionofSmri,n?0:ll5hyrtry
<br />lttlicrDlforaNhnirsub.Jcccth.rftlicrnlroacivillcirlry.fnr'frtrcrhanfivchundrcddollrrs(t50O)
<br />I. x\ osrcr of Il[ I,nrFny. or ity cnt,lotc.\ wiih wr8e\ as rhcir {nc conrp.Nrri(,n. qill do r}r uo& ilkl Ih. {ft1m $ nur
<br />inlcodLn or olliEd Inr st (s$.704,1. tsusiricss ,trd Prorassi,ris C( c: Thc (.N,ctn s Li.ctr* Uw docs nol anDly x, an owncr ol
<br />rhcpmlj.ny uhohuild\orinlmvcsrlf,di,afll*hodcssuch*orthimscllorhc^clrorihn)urhhi\orh.r.wic
<br />'ploycc\,rovidc'l rhar su.h irnlmrcnEnls m mr i cd.rt oi olldl f{tr slc. ll howcrr. r,r hu ilding or i'n tuvc $ i1 st1 wlhir onc ]qtr
<br />ol Lloqrlcri{r!, rh. O*Nr auilild qill hnvc rh. hrd.n ofpn,ring rtur ts or \hc did nor build or ilnpm\r rh. Impcny for rhc l[IIb{ ol
<br />-1.
<br />!s owncr orrhc pn,n dy. rmcrlusivrlycotrtr.rinp wnh L..ntcl . o nrn.kn s to connrucl lhc p(&d (S(. 7014, Bt\in$\ot lhni\ri,n Codc:'I'h. Conrracroir Liccns. k*.locs nor lpply k' an ownc'.aprcpcn, *io brilds or inptulcs rh$cui.
<br />lnd *ho conracts lor such Irojccis sirh a Co mctonI liccnrcd l[su!trr r. rh. C{,nr.cktr s Licens ljw)
<br />-l
<br />ureicmfl undcrsalion . B & PC forlnhrcontr
<br />Owftr:
<br />1YOAffru_C()UtrNSArt0!
<br />lzllcLrlBAllo!
<br />I hcrcby rilimr u Mcr p,mlty ., pcrjMy otrc ol rhc follownrt dccldd t rs:
<br />I hrvc Mdwill nhir ri',6CcnificicolCon\crrhScllln\urcr(,$orlcFcoflr|xn\lriotr.r\ ImviJcd f(n hyS(rnnr17fi|o, rlr
<br />t-ahrCod..inrrhcpc n.man.colrhcsorklor*hi.hrhcpcrmir i\n\u.d
<br />-lhrvcrndwillmrinrainworkcn
<br />conrpcns.rion insurancc. as rclnncd hySccriorlT(xrofrhc Llhor Codc, tn rhc Frron',ftc or
<br />thc trr't ln, sh'.h rhi\ nrnrl i\ n{aL workcs conrNnsdion irNurnncc(dcr d F licy numbq arc
<br />.,r,,". s-2L 11
<br />I c.diliihrr in rh.pc{ormnce {)rrhc sork tor shi.hrhn p.!ni i\ t\ucd.I fiall nor c'npk'y r'rt pcr{,n in riy uin&
<br />a s fu tuom \uhi.r k rhc sorkdi\' .on!rn\d n,. h*! of Crlifunh, nid r!r.c rhd ir I should trorc suhjcct lo lhc
<br />\olk.rJ onrlcnsrrion ltu\ isions of sccrim l?fir of rhr Lltxr c.dr. I \hrll. nfl hwirh (nnfly wirh tho{ pmvisionr
<br />WARNINC F{ilurc kr {cnrc sorker(.on4.Ds ion dnctue. i\ utrhwful. n firll subj.cr ur emDloycr rr ri'liralIf, xlric\ and
<br />.ivil ftrcs uD h onc hundrcd rhousr.d dollrs rslm,uro nsation. drnuEcs us p'.!id.d in rhc
<br />,,,", ol7t t(
<br />^
<br />DIILABII()I
<br />I lrrchyrlltnuDdcr Ntrulry ofNrjury rhdr I . li.c *l u {lcr pRrvi\i,)i ofClrpr$ 9 (.onnfr'n rtg t[h Sdi,n 7(U)) .t l)irision :]
<br />of rhc Ar\i'rcs\ rdd Prufcs\bn\Codc. nnd my liccnsc i\ i0 ful!inrcc ud cfl:ccr
<br />",,-lrot73b,",",q- 81.1,(
<br />taNslf,lcrl0NlElDllc-&{iElLl
<br />IhcrubyrllirnxilcrpcnslryofrrrjoryrhnrrhcBi\tr.ondtocrionicndin8rgcrcyntrrhcFrfomn.cofrhcrorklbrshtrhthlslrmriris
<br />i\\!cd (Scc l0)?. Civ. C.)
<br />a.tfuc6lfDEclA.SauoN
<br />I lrn$y linn!odcr p.nrlryolpc,jury onc orrh. followins dc.larolions
<br />Dlmlilion lrcnnirlAsbcslos Norir'ic!ln,n ftdcr!l Rccuhrions (lilc 40. Fan6)
<br />RrqtrtcJ l,crrcrolNori,iorirn
<br />-l
<br />ccnifyrhd rhc ltd.i.l rc3uld iors rc! din8 as$.nos rcnDvil rc mt 0trli.ahlc to ihh pmrcr.
<br />)ql cc irythd lh,vc rcddthi\ ilrlic,r ion onl sr.r. r har .omr. I n8r.! ro conrply sith all Cirylnd Coutrry
<br />.rdnrn cs.6d Srric UwsrcL inttu bu rc*n( rivc\ o r $n City .nd Counly ro cntcr uIx,n rlE
<br />h,rc nrl tr,rcd I,oNnr- rnr
<br />y"4a1_k
<br />Set Backs
<br />Erection Pads
<br />SLAB Floor
<br />Subf loor/VenVlnsu lation
<br />Rool Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Ene rgy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ir/asonry
<br />Pool Fence
<br />T-Bar
<br />tlandicap Req.
<br />D uty Final Report
<br />Engineer Final Report
<br />FINAL Q lz-t rB bu 9',)"/.ir\ 4/4?rO)
<br />Certilicate of Occu Ipancy
<br />SITE-WORK
<br />lnc.
<br />ADpli(nnl o. A|l€nl SiInalrrrc q\F
<br />Formsi Steel/Holdowns
<br />UFER Ground
<br />Flood Zone Certif .
<br />Notes, Remarks, Etc.
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