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BUILDING. INSPECTOR BECORD
<br />SITE-WORK DATE rD/srG.COMMENTS OWNER BUILDIiR DELCARATION
<br />I hcrel'y rnirnr utrds pcnalry of pc.jury rhor I afl cxcnpr tm'n rhc Cotrrracro^ Licene ljw t{tr rh.ldk,wi,rr i.A$n (Sc.70ll5
<br />Busine$ nnd Pnfcssior Codc): Any Cily or Counly which rcqutcs 0 rEnnir lo connncr. rhcr. inrriov.. dcmlnh or rcnJn Jny
<br />{tudm- rrbrro ir\ hsramc. nko rcquids rhcnnplicair fd \ochr4mir ro filca sisnrd nrtcrftnr th h.or shc is liccDscd puEur r
<br />t,
<br />'hc
<br />pmvnion\ of rhc Corrrscxn s l-icenscd ljw (Chuprcr 9. Comnrncii! wilh s..rnnr TlxD or Division I of rhc Burincs lnd
<br />Prolissns CodcJ or rh.r h. .r shc is crco rturcfrom md rhc hNs for rhc illcgcd cxempl ion Anyviol&lionofSc.ri.n7011.5bynny
<br />amlicanr for a pcmil slhjcll rhc applicur ro a civil p.na h y oI nol more rhu filc hondrcd dollm ($500).
<br />-1,
<br />os owtr$ ol r hc pmlrdy. or my c,nploFcs Birh wagcs .s rlrn s[ conlPcns0rion. *ill do rhc *orl md rh. srmruE is mt
<br />i' c icd or oficrcd lor elc (Sr ?044. Busincs od Pnlc!\n n\ C{ . Th. Conr*tof s Liccnsc Ijw d.cs n.r lPply io an osi.t of
<br />rhclmlEny who hildsor in0ow\ $cren. aod sho d@\ such md hirn\cllor h.r{lfor rh()u8h hh or hcr own enrLycts,
<br />pr.vid.drhar su.h idrR,wn..h m mt inr.ndcd o.oficnd for snL.ll hoacvcr, rhc builiir8.r inDmrcrtnr i{ $ld wirhinom ttd
<br />olo'rokriD rhc O*mr Auillq willhavc rnc b{dcn olpovinB thar nc or shc dil mr trild or iryrolc rhc pd!.ny ror ihc pura)s.l
<br />-1.!sowncroilhcl)()l)cny.aDcxclusivclycontrldirgBirhliccnsdconrracronrocon$rucrrtupn,jccr(Scc
<br />7O!r.8u!i c\s
<br />rftl lbfcsi.nCoJc. Th.Cont&ror's t-i.dns. Lrwdocs norlttlyt, rnowncrol !mp! ywhobuildsornnlrovcsrhcrdrd,
<br />rtr( *ho contrtrdsfor such proJc.rswirha Co racront liccnscd pursutrnr torhcConrrucro s l,kcnlc ljw)
<br />-l0rcxcnrpt
<br />undcrSsrion-. B & P.C. fo hi rc.n)n
<br />ITAXTE&SIAMPJIIAIION
<br />DEIIAIAIION
<br />I herchy ailnmundcr pcnrlly ol lsjury om olthc lollowin8 dcclenrions
<br />-l
<br />hlvc ard s ill minrcin a Cerrificsr. of Gn,*!i ro Sclf lnsurc ttr sorkcre conp.n\ar ion. * Frvidcd ror by Sccrbn l?(]t) of lhc
<br />l-rhor Cde. rd thc ptrfo,rrErcc o, thc work lor *hich rhc pc,rni t n\ucd
<br />Ihdrr *illn,xinrrinworkcrron,t^-n\ari{,ni'runncc.NrcqutdbtSccrtun:l7U).frhcInhorC.dc.li,rllrcrcnbnunc.ol
<br />rhc Rork tr which rhillf,rnriri\ isLrd Myworkc^ .ontp.n\dn'n nNu'dn...nricr tuxl8ni.ynun$cr c:
<br />l.cnily rhrr ir rh. pcrli)i!roh-'c olrhc *or[ f.r *hi.h rhi\ pcrmir i\is{rtl.Irhnlltror..yanylrsorr.aoyntann.r
<br />$ $ lo h(dnrE suh]cd ro rhc *orkc6' corlpcn$rion laus ol CrliLmiu. ind |l8rcc rhar il I should hecom sthjd k, rhc
<br />*orkcri co'npcnsariotr ptr,vhions otSccrion -17{Dofrhc ljtnr C,xlc- I \hrll- r'onhlirhconfly sirh rlx,t piovis.n{
<br />VARNING Fsilut r, *.uru workcrs .otrFn!{ion ..vcrug. i\ rrhwful. ,trd shnll \uDjccr 3r cnDlo}s ro crinriml ll:tu'hi3s md
<br />.n'l lnr\ trf t) ont huiJrud rhou\ id dolln^ (31(X).(XX)r. ni coN of.onrNmaln& drruScs r\ F,vidcd n,lhc
<br />sc.ri{trr:1076 0frhc lr}incrxlc idcrc{rtrd rr.rmv s r'dcs
<br />.l-r-G r!
<br />DECI.ABAIIOX
<br />I h.rcby anirm undcr pcnahyolpcrjury rhol I am licctrki undcr Imvtion of Chopts 9 {connmncinB ,ilh Seri,n 70m) orDivNiotr 1
<br />ol rh. Busin.isand Profcssions Codc, iM my li.cns. is in tull fum dd cflari.
<br />l-ienscCh$-
<br />CANSIBJJCIIONIIIDINIj.ACENII
<br />I hcrchy nffiro undd pendry.rpcrjuryrhst rhcrc k,.onsrdcli,n lcndins nC.n.y fo. rl[ pclluflrDtrc..flhc vork for *hich rhis ron'ir G
<br />issu.d (Se 3U97. Civ C )
<br />APILICANLIES.AAAIIAN
<br />lLn$y lnt'n utulcr p.nrllyorpcrjury om olrhd rou.wing d.claturi.ns:
<br />Dctulrion Pcrnils Ashsros Norincarion FcdcralRcgllariotrs (TirL 40. P!n6)
<br />-Rcqutcd
<br />I.iler o, NolilEarion
<br />I rrn,lilhJr rlr ltdorrl rc!!lrt,,n\ rc8ulnr! rnrno\ rrnmrrl nrc noraptli.rhlc r, rhis pni.,c.r
<br />-l
<br />ccnifyrhd I h!rc rcad rhir ol)Plicar ion ed (olc rharrhc at-vc irlonmrion ncomd.I aBre ro comDly wirh allCny and counry
<br />orJinrKc\ and Srarc Lrtr( (lJli'8 r. bui]ilngF.{rrudrfl', tun hcrcby.nhorizc rc,rc{nr0rivcs ofrhh Cirylnd Cou.ryb.nrd ulbnrtr.*,,,,/"-J-.1 /-/
<br />n***,-n*-,',**.i *Sf!dJ,4 ,,," { a("-u'
<br />p.mre h.m. {prin,,: La u riln- "1?e.
<br />' n l'
<br />Set Backs
<br />Formsi Steeli Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Su bf loor/VenVlnsu lation
<br />Rqol Sheathing
<br />Shear Wall
<br />Framing
<br />Insulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Mason rY
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil.
<br />FINAL /r/,tz/:t 6nt(
<br />Certif icate of Occupancy
<br />N oles, Remarks, Etc
<br />" fiL frt nuAi.u a
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