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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUTLDER DEI-CARATION
<br />I hcrchy atfinn rndcr p$rky oi pctjury rhll I m cxcmrl tio'n rhc Q)nh.Mr Liccnsc k* r.r rhc rollowin8 tcaqrn (s..70:ll 5
<br />B!\incsr drl Piofcssion Codc) Atry Cny .r Corm, thi.h r.quncs I |E mii tr .o nfl.r. rlrer. imln,vc- &nr)lM or Elan atrv
<br />{tu.rurc. prior ro ns kruancc. al$ (quntsthc rmlicatrr lbi such tlcirnirti tilc, signcd (0tcnrnr rhar h.or shc ( liccnsd I'!6u!d
<br />t, rhc tri,visi,,n{ olttE Contrxtr\ l-i.ci\.d l-,* (Ch,flcr 9. &nnaEncins *irh s..rion 70u) or Djvision.r or rh. Bxcin.s{,nd
<br />Pn,rrsnns Codc) or thal lE or rh. r crd rfl rh.rcnoD ind rhc hrsG tu rh. dlc!.d crcmnrion Aaylidrri{ olscdionT0:ll.5bvrn,
<br />!rplionr lbrrpcnnit suhjN( rhc applicrnl ro acililp.0rlryol nor t,rclh r ivc h!ndrcJ dollds($5(x))
<br />-1.
<br />rs ovncr oa rhc pnrFny, or nry cmplo)ecs wilh wsscs ,\ rhdn $k conu.n$ftn. *ill do rrr wolk 8nd thc slturm k "r
<br />inrcndLal orofftrcd rorelc(Sa.7044. Businc$ atul Prc{c$i.ns Cqlc: 'l hc Gnnhdor's Lkcn* tiw dNs nol u,Dly lo oBncroi
<br />rh. In)tEny wlb t{ilds.r iq,.rt\ rhcftn. md who dcs ssh wor,{ hinNclror hft*lfor thmush hn or h.r o*n.ry,lovce\'
<br />pi,,vidcd rhar \!.h intmsnEnF m mr inrcdcd or olIcrcd fd ilc Il hlvcq. rhc bdilding tr imlmrcmnt is sld wnhin oft
<br />'trof.otrplcrhn. thc Osne. Blikid vill hnR lh. burdcn ol novin8 lhd hc or shc did mt t oild or i,ipnk rh. l)R)ltdv nn d. t'rloe or
<br />-1.!soenerorrllepmp.dr.!mcrclusivcly.oohcringwirhli.cn{dconra.tonroconqd.rrh.rroiccr(S$
<br />70'l]r.3 \i"cs
<br />and Pn)l6sion Codc: Trr ConrracroCr Lic.nsc L{N does norlonly ro an orncr ofrrop€ny *h(, huildr ur nnrrorcs rhcreon.
<br />rnd who cona.cts for suct rmjccl\ wirh aConr.J.roig li.cnscd Nrux.rh rhc cont.chls l-icenk uw).
<br />I rnrcx.nrpr utrdcr Sciio
<br />thl., Own.r:
<br />WORKr]R.$ COM'!iN.ATIoN
<br />I2licld3a.uQ
<br />I hcrby rtiifl. u.d.r pcnahy ofpcrjfiyon..rrh. followiflE dr_larolbns:
<br />-lhav.mdwillmintoinrCcnilicarcorCo.\cdrroscla.lnsurcfor$orkcr'dnnpcns,non.aslmvidcdfotbyscdion:1700olrhcLabor Codc- fff rhc pjrr.mncc of lhc w.rt tor *tich rhc ,cmi' i{ rssucd.
<br />I lrrtrtrd will nri rin wo*cs co rpctr\rli( Nurro.c- r\ r{uncd h) Sc.ri.tr l7lx).irhc l-rhntCodu. br rhc Frlonn,i.cuf
<br />rlrsorkturqhi.hlIh!.nniri\i\sucd.Myworkcr'corDcnsrri{nri'r{trtr.c.rnicrmdrniryno$crrc]
<br />-l
<br />ccnilyrhar inrhc pdronrtsrc ol rhc work t, Nhichrhi\ I,cnnn is issucl.l sh3llhor cnrdoyrryler{'i in riy r.nrct
<br />$ a\ h b(oN slbicr t, rhc workc^ com|fN ion 10ws oi Cnlinnnia. rnd rStc rhlt if I sh,uil h... f, subF...r lo rhc
<br />sukcs <nntcnsatt,n px,v(i,,ns ofs.crion 37u)olrhc I"tin c(xlc,I \hrll. li'nh'irhconrly wirh rl$c Povisions
<br />IIARNINC Frilurc ro scurc sorkc^' con,|xhariod ..v.[3c is unhwtul, rd shrl] subl..r I'r. rtli,ycr kr lrnninlltc.rlris lnd
<br />.ivil nnc\ulroorchundEdrhou{trddolhtrs($100.(xxl).inaddirionkrrhccurrolconrFtrs'rn.dnmr8cs!\pnvi{lfll r{tr rl''
<br />So.r( lo7(, ol rlrc L,txnC{nlc. i rcrci rtrd
<br />Dxte A Ae;-.r-@
<br />DECLdAAIION
<br />I hcrcby atfirn und.' r.n0htoilcrjury lhll I am li.rn{d und.r pmvisin otChlpicr 9 (snnftminB wilh S(rion 700Or'rl)ivhion l
<br />or rhc Businc$lnd PrcfcsnnsCodc. ud,ny liccns is in aull r.rce t lullccr
<br />2e-*
<br />CoNS RUCTTON ! FNOIN(: ACENCY
<br />I hc'chy u,ttn undcr p.mhyoip,rjury rhlr rhcre i\ acon{tucri,n Lndiu r8ctrcy ftx rhc lcnnirrrmc olrh. eork ritr shich thn Pcnnil is
<br />issucd (s(. 3097- civ c )
<br />Lcndq\ Ad.I.*
<br />-
<br />ASELUANfDI.CIABTIUA!
<br />I lfr$y altim rndft p.irlly o, Nrjry onc ofrnc ro]bwin! dcclantri.ns:
<br />DcnNliliur Pcrmih Ashcios Nolili.dti$ l'cdmrl Rcauhr ion\ (Tiilc 40.1'r 6)
<br />Rcquicd lllrr or Norill.rr of
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Roof Sheathino
<br />Shear Wall
<br />Framinq
<br />lnsulation/Eneroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />Masonry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL
<br />Certificate ot Occupancy
<br />Notes, Remarks, Etc
<br />-l
<br />cdniry thar lh. fcdc.ll rcBulll ioos Esarding asb. os rcn$v0l!,c nol apPlitahh ro this lrojccl.
<br />I..nilylhd I h.vc icld lhn a ,licdrionord $0lclhat lhc !bo!c inlon. n,n s conccl I aBrE xr d,ry)ly wirh all Cil v rnd C.unrv
<br />onlin,Rcs ond Srnlc Laws rlirins b hxrlding lonidction. and hc,cb) DUrhrr,. rcprcscnrarec! orrhn ci, lnd Cnunrv lo.mc. ur.n ItE
<br />rh.!c trrrn'trd f'.Fn) rn in,Fdn'np,r1,F.r /)0
<br />,rppr.mr*,re*,sis*r*" kqe.-'J+ ^*9lrrll8
<br />pem,ir* Ehq,prh,,: ' ' /.--ar,tIs v,(l<r-
<br />T-Bar
<br />Flood Zone Certif.
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