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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BU!LDER DELCARATION
<br />I hcr.by dfi n undfi ,.n,lry or rcrjury rhat I en cxcnfr rturn rhc (tftadoN Liccnsc Liw lor ihc iollo{in8iclv'n lsec 70ll 5
<br />Busi'E$ ard Pmits\i.n Cdc) Any City or Coutrry shich r.qutcs r nrrlil lo consltoct. allm. imlrov€. dcml(h or ft, r .iy
<br />{rucr!rc. pdorro irs issuancc. llso rcqlncs rhc q,plicMr tbr such pcrnir rd rilc r signcd darctunr rhar h. or shc i. liccnscd pursanr
<br />to rhc provisions of rtr Conkrclols Licctrscd t w (Cnaprcr 9. ComnEncin8 *ith Sc.lion 7OO0 oI Di!i\n,n I .r rhc Busincss and
<br />PDlcsionr Code)orthal hcorshc ircxcnr!,lthcrcfromun( th.h$h lor rh.trllc! .rcnprioi nyvnn,'ionofSccliotr70.ll.5l'ylny
<br />aftlic.ntror,lcirnnsubrcckihc.mlican!loa.rvrlpcMlryorn.rm.rcrhaiivchundrcddollam($5d)1.
<br />I. r\ owicr of rhc IrolErrt. or my cnDloyes *irh $"gc\ rs rhcn $,b coml.ns,h.n. wrll do rh( work iM Dr slrucrurc i\ lor
<br />irlcdcd or ofcr.d lar elc (Sd.?O4-1. Brsincss and Pmfr*i(,ns Codc Thc CoDtr{.rols Liccnsc tiu d.es nollpply t, di osn$of
<br />rhcpn,Fny *tx, huilds or impmws rtrEr, aDd sho dms \uch sllrk hinxclfor hc^clf.r rhrouSh his or hcr ow!.n{rloyccs.
<br />prclnlcd Ih rsuch irnprcvcnEnr arc (n i.rendcdorotaEd for *rlc lt ho$cr.L rhc hildi',! or inlpmlctu israkl wirhiD.nc r(
<br />ol(nwh!i(,i. rhc Oancr Auillld will hrvc rh bun]tn ofpn,ving rhrr h..r $. did n, buik] or inrJlloK lhc I'mtcny,nrll{ puqx,*.f
<br />-l.
<br />rs owrur of rhc pm|cdy, anr cxclusivcly conradinS sith li.cnsd conuacl,'r ro con(tucr rlt poJccr (Scc 7t,14. 3ultEs
<br />a l Pbfcs\i,nCode:'lhcConta.roisLic.ns.Lawdoc\dorrtrtlyk,atrowmrdlpropc,sho$uildsorimpmvesrhcrn,..
<br />a.d who oftads tor su.h rroFlts with a Conrrocro(s) liccnscd purunnt rorheCod.!.t.is Li.cn* trw)
<br />I rncxc U undcr sc.*" ? /z-t
<br />DECIAMIIIJN
<br />I hcrcby alrtmundcr peMllyofpqjuryonc ol rhc lollorir8 dNlarnrions
<br />-l
<br />h!!c frl will nEinrain ! Ccn iararc of Concnr ro Sclt- lnsurc rd workcs comrEnsarion. a\ poviddJ ror by s.rr nn lr(xj .l rhc
<br />tjtxtr C.dc. f.r rhc ncrf.iimDc. ofrhc work lor which rhc Nnnn i\ issucd
<br />I hr\c.nd sillnrflain workcr{ com!.nsrrio" insututrcc..s rcqutcd hyScdi.n:17(x)olrh.l2horCodc. for rht frr{Drnhrc of
<br />lhc worklorwhich rlis p.rnir ir issucd. Myworkcrl cotr1tEtrs,ri.tr insurin(ccmicr dn,xnicynumb.r trrc:
<br />Poli.v Nun$.r: ExDir\
<br />I ccnilyrhirin rhcFrloiimncc ofrhc sork ftn *hi.hrhi\ ncnn t n\ucd. I nrll dor c]\Jloy nny lx^.r ir Jnt nnnmr
<br />srastultd,nd\xhic.rk,rh.*.rk.s'.on{'cn$rnDlnerorcrliltirii.rrlagrudhrliilshoul(lhcconE\uhtcrk,rhc
<br />workcs onpctr\rli( pkrvisions ol Sccrim 17u)ol thc ljlnr C.xtc.I rhrll.lbnhs rh.otr{ly xirh ik){ pn,lni,nrs
<br />WARNIN(; Ij lurc h ruru qorkcr\ con{rn\ ion.ovcraac is liliwrul. and \hrll \ubrc.l !r cmnl,,Fr ni rnninrl n('ulric\ iM
<br />I lrtohynthnundcr pcnrlryofFrjrryrhar I ad li.cn{.Iundcr pmvi\n ofChn d9lc.nnrrmre wfhScclion 7O(l)) olDivi\n,n.]
<br />ot lhc Btr\ioc$lnd Profcsions Codc- lnd my li.cne h in tullnreaftlclfsr
<br />ctlNsrBlcltaNrtiNDali-&c[Ncr
<br />Ilrnbyrl6nnundcrFndlry.fFrluryrhdlhcrcisrconjrucrionlclld,ngrgcncyforlhcpsloruiccotlhcsorlforwhihrhh!.tnniis
<br />issucd lscc :1097, Ci!. C )
<br />AISLICANLDECI.ASAIION
<br />I laJlby allm uider penalry orperjury.ic ofrh. nrhwins d..lotrrion\:
<br />D.nmlilion Pcrnnts-Asbcsros Nor icarion rcdc.rl Rc3uhrn'ns (Tirlc.l0. fan6l
<br />-Rcqutcd
<br />Lcrrs o, Norillcariur
<br />I..difyrlr.r rhc fcddr rcEuhr.ns ogddnrg rsbc .s r. bul ar nor rpllnblc h lhls protccr
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<br />c.n iiy rh,r I h,rc rc.d rhis aFtlicsrio. ud iatdh{t rhc ahvc intbrnEr ion h cotrd I asE ro .uply wirh rll Ciry md CoDn'y
<br />odimnccs .nd Shl. Iaws rcldin8 Iobuildiuconnrudion.mdhcrcbyrurhorizcrcprc\enrarivesofrhi\Cir,atrdCoumylocr$uponrhc
<br />xh^r trf, rnnrcd B)ncnyl(tr i'rtfcdnnr Nllr'{\
<br /> ppliurn ur r\,:61 Sir$ lurr
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />It/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />De puty Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />l t\ -\
<br />FINAL rll ltt4 ",Ury14Certif icate ol Occupancy - r' I t-
<br />Notes, Remarks, Etc
<br />Forms/Steel/Holdowns
<br />Brown Coat
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