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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE IDiSIG.COMMENTS OWNER BUILDER DELCARA'T'!ON
<br />I h$.by rfflrtu utuld pcn,lry (,r Frjury rhar I m cxcnll)t lmn rhc Conlr0clo6 l-iccn* liw ror rh. r.llowirrg rcasn (Scc '70:1
<br />1 .5
<br />ausiD.ss Md Prolcsion Cod.): A.y Cny or Cou.ly wnich rcquircs r pcml lo .{neru.r. ,llcr. nnP.o!c, dcmohh or Eplt My
<br />{ructurc, l]rD.rr, irs issuaocc. rkorequircs rhcappliconr ror such lEnni b nha ngncd sa'.ftnr lhd hcorshc is lice!*d ,xfsnr
<br />io lhc lrovkions ol rh. Cotrt,ctors Liccnscd Liw (Chrrtcr 9- Commcncin8 wirt sc.rn,n 7000 Dr Divirion I oI lhc Busincs and!
<br />PtufcssionsCodc)orrlErhcorshci!crcnprrhcrcfromrndrh.bsdsfdrhcrllqcdcxcnrlion.AnylioldionofS(ri)n70ll5hyany
<br />ipplicanr lbr a !.rmn srhjea rhc applicsnrto acivil[l.n.lryot mr mlc rhan fiv. hr.drd doll,is ($5u))
<br />L ns oun.r or rh. rdrcny, .r nry .nployc.s wirh wN8cs N rhcr soL conrpcoslrion- aill d. ltE *or* and rrt sflrm i rn
<br />inreNlcd or ofcrcd lo slc (Scc.7044, Businc$ lnd t\ofc$nnN Codc: thc c()ntmttr s Liccn* L2* do8 not .pply lo an osncr oi
<br />th. n$p.dy *k, builds or inpmB rtENn..Jx, wh. d6 skh so* hnnsclfor hcrslfo. thmuAh hn or hcr o*tr cmpk,yccs.
<br />Imlidcd rlur such i,nnrolcmn* m nor i c'rdcd or ofltr$ nn sb ti how.hr, rh. huiiln{ .r i,rytuvcm is sold wirhin nnc }tr
<br />of conphlnnr th. owncr Buildcr will haE rh. budcn ol Imving rh h. or shc dil mr huiu or nnpovc rh. rn Fiy ror rhc P!4re ol
<br />-1,
<br />osowncr nflhc flopcny. anqclusivclyconrncri.s *irh liccnscd conrrchN t, con{ru.r rlf tr+cr (S(. 70{4- Au\inr\\
<br />rntl Blt*sbn Codc: Thc Co.rNror's Li.cnsc Llw docs nor dpply ro m owncr oipropclty wni) brilds.r nnpiovcs rh&cor.
<br />and 'ho conhcls aor such rojcdr wirh r Coirrack,(s) liccoscd pulsunr t, rhc Coftacror'r Liccn€ tjw)
<br />-l
<br />ncxcmpr undcr Scc'B ttP c"Ie,ik Kr /2:2412 :1't r't <r
<br />D[CLrIA3II()!
<br />I hcr.br rffinn trndcr pcmlryofpctury oic ofrhc n,ll,win! d.clrnri(r}l
<br />I hd\tMd will rinrr'rdCcnifi.ircofCo.sctrrhsclflNurchruorkcricorr|.n\dio,.xsl)n,vi,lcdlnrhysLrrrnlTr)oolrhc
<br />ljhr C{xlc. for rhc p.rioriMncc ofrhc work for $hi.h Ihc Fnnir is r\\ucd.
<br />-lhrvcr.duillrnrirlrirworktG
<br />comp.nsalnrn inrrrk-.c. rs rquitu',.l by Sccri,r:171$ olrh. tibor Codc,ltr lhc pctiorron.cof
<br />rhc $ork i$whichrnis pcnnil is iss&d Myworkcrs conrpcnsrrion iNumncc caricr &d p.ticynunrhcrdc:
<br />Policy Nunlbft:-Expircs
<br />-l
<br />clnilylhlt in thcpcrlormameotlhc work lbr whicn rhn pcn,il is i\\udd.l shdllnor cntl,ryany pcson inanymanncr
<br />e nsro tEcom subj.cr ro rh. workcr ompcns.ron hws.lColiromi!. md l3Ec
<br />'hot
<br />ill stould bccotu srbjer ro rh.
<br />workcm omr.nsorion trovkions ofSccrion:ll0ooflhc hrnr Codc,l shdl. fonhqnh.omrly with rho* ptolisions
<br />WARNtr{Gr Failui. ro sm woikcrs $npcnerion .oktusc '\ dnhqrul. ud $ell subjccr M cmlll Fr h, hmtrrl lxmlric. dd
<br />civil finc\ up ro onc hundrod rbusrtrd dollds (Sloo,(x)o). 'n,,t,lrnn rc r*,Urt( otutl'mrrnvti,.n. ,i,'uCcs ri fr.vilcd t)t lhc
<br />s(f'un rOTo ol rhc lrb.rCnd.. trrcrca dJirorm) \rN. .Z ,/, ,/
<br />**.A.-'J.|.:/9 App,ion,: M 2 t'/1"'' z'
<br />LlutrirED uoNT'RA("I(tR
<br />DECIJBA.IIAN
<br />I hcrcbyrlit'nunder p.naltyofp€rjurrlhal I !m lilrnrd undcr polnnnr of ChrDrd 9 (co rmncing wnh Sccriotr 7{X[) olDivisi.n.]
<br />of rhc Busncss rnd Proli$iorN Codc, a my licctrsc h in tullIorc.ndcffccr.
<br />CI}NIIBIJCIIONIENIA$IGENEI
<br />I hcrby rl1irm undcr r.mlry of p.gury thal lhnc is s onstocrb. bndi.8 aScncy lor llE pcrlonutuc ofihc wor* fot which rhis lclnril is
<br />isucd (Sc..:1097,Ci! C )
<br />AfTLICANLDIj.CLA8AUAX
<br />I hcrc5y ofijm u ndcr !.nolty o, perjury onc ol lhc lbllos,i.E dElarrriolr
<br />DcnmlirMrPcnnirsAsb.iosNoliicrlionl-idcrrl Rc8uldionsllillc40. Pnn6)
<br />-Rcquncd
<br />Grtcrol No'iljcalhtr
<br />I ccnilythd rh fcdcrdrcBtrldtiotrsrg0rdrBasbcstosrctrDulnrc mt anllicablc ro rhi\ pmlccr
<br />-lcnililhlr
<br />I hnlc rcad rhislprl ly wnh rllCiryund Counly
<br />L! ud Counry to cnrcr upon rhcordinlmcs lnd Slare ltrws El,rins ro
<br />ilrtr. r.ri(,rn Dturcrrylnr Q-rr'rg,\ppliu l0r,\srtrl Sixtr luFcui?/ / tv/t/rt<
<br />Forms/Steeli Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenUlnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Ene rgy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil
<br />FINAL 7u(M'ry -x,*eal >z)
<br />Certificate ol Occu Upancy
<br />Noteg, ReJnarks, Etc
<br />b o
<br />Set Backs
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