BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.oWNIR B(IIt-DER DI]LCARA'IION
<br />I furcby rlftn undcr pcnalry {,1Nrjury ll l nm cxcn{'l ln)m lhc (.onl,u.lor l-tcn\c Law in rhc hlk,wi,rg rcan (S..70]l 5
<br />Btrxinc$ nd Profc$nrn Codc): Any Cily or G'unr, whi(h .cqutcs n lcnni n, ..i{tu.r, ,lrcr. nllt)n,vc. dcmoli\h or r{tn any
<br />dtu.rure. prin ro irs nsuancc. rho rcqut$ rh. applica tur {Eh pcmir h rilla siln.d {arc rnl (har r.or shc n li.cnsd Nr$anr
<br />tu rhc rroviioN orrh. conradols Liccrs.d tjw (chlprcr 9. Conmrc..inr *irh Scclion 70(X) ot Dilin,n I of rhc 3u\inc\s and
<br />PnlcsionsCodc)orrhor hcorshc i\cxc'rpr rhcrctrom od rhcblsh ior rh. all.gL{ cr.'nlton. An! vnnrri(inofS..liotrl03l.5 byany
<br />afrrlic,Dr nri p.rnin su\c.krhc l,)plicmr t) r.ivilpctrirryornor trbrulhitr llvc hutrdrcddollus (S5lt))
<br />l.!\o*rcrolrhcl]rolEny.ornrytnrloyc.\snh*rgc\ssrhcirvnoco'npcnldioi.*illdorh.workaMrhc{Mrurci\n-r
<br />i cltld orofcrcd for sk (SN r(N4. Busirx\s trnd Prcltssion\ Codc Thc (-onr0dois Ltcnsc li$ docs nor$ply h rn o*nrof
<br />rhcpmrcny sIx' buil{k or lnqnolcs rhcc)n,,'d *ho dtr\ \uch {o* hinxcllor hjrscltoi rhn,lth his or hcr oulr cD'plo}c$.
<br />In ovidcd th[ su.h iDpmvcnEnrs arc nor inlcndcd d otIcrc lin qh ll howc(r, lhc huikling or inrtmvcn-trr is s,ld virhir
<br />'
<br />{r( Frr
<br />of.o'qrlcri({ rltr owncr Buikl$ w l havc rh. hudcn of F)vi'r! rhrl hc or chc id mr hoitlor irrlirolc rhc fmtcny ior rhc pdrF's.f
<br />_1.!so*nqoirlrcorop.rrr.ancr.lu\ivclyconrrrrinssirhliccnrdconkrctn\bcon{rucrrhcr{,jc(r(sLr 7or4,3u!rcss
<br />ind Pn *\6. Cidc: Th. CotrLrkr'\ Li.cnso Law docs mi apr ly ro n owmr ol proncrl, s'h() t uilds .r nnpi.rc! rh.'.o .
<br />rtrd who r.Drrn tstor $ch F)jccrs $irh ! Conrrrcro(, lic.n{d pursu n,rhcContil.tr\ l-icctrk hw).
<br />-laflcxcmpl
<br />und.rsali r-.B &PC forlhhrcas.n
<br />D{le Oener:
<br />wOt<r'tY CoUn'Nslrrol
<br />DICLdXAIIO!
<br />I hcrchy rlnm unlcr pcnllryofp.rury onc oirlt follosin! dcclararion!:
<br />I h3r rndsill mrinrxii rC.nificrrcotCon\cm b Scllln\urc ftn sorLcN.o rf,.trsnitr{r, i\ providctlntrbySccri{nrl7(x)olrh.
<br />l.!ho! Cqlc. lnr lhc pcrlornuncc oirhe work ritr slrich rhc r!:nnir i\ isucd
<br />_l hlvcrid{illm,inhin$orkc.a c.mpensrtion inluiancc. trs (quir.dbysNrionlT0Oo,rhcLlborCodc.lorlhepcriornrnccnf
<br />rhc suk l, s Fih rhh pcmir ir ts.u.n Vys.,l,l.'n,Frl!.nsrh,,n 'n.u,ra..Drrr rnd
<br />'.lk)
<br />nun'bcr m'
<br />crrrcr Staie lund
<br />Lil 3s6 t1
<br />---Expnr\:
<br />lccnity rhrr in rhc pcrfonu,kc i)frh. work tu whkh rhi\ pc nir r\ i\rucd.I shJllnor cnrfloy {nyn!^on inrny mMncr
<br />$ s lo hcom subjcct I.lhc {orkc6 co'np!tre ion lss\ oi Crli,i,mtu. a.d rgto. ihri ill lh,ukl tt o.rc (trhF_r rorhc
<br />workcrs conrFnslrion provtt,n\ ofscclion:l70Ootlhc L:'h, Codc.lslvll ranhsnh.o rdy wir h lno* lrovnions
<br />WARNIN(;: I{ihrc r, \dcurc qorkc* coln|xtr{liotr .orcfu8c i( url.wtul. rtrd shrll suhiccr 3n cn,ploycr k, oininrl ff,trnhics dd
<br />.ivil Anr\ xn ti oid hundrcd rhousrnd dolh^ ($lm.(Xlo) i. ddiri.tr ro rhc con ol'coour$lliotr. drrogcs a\ ln)vidcd lor rhc
<br />Sc.rion:1076 ol rhc hhl CoCc, mrcrcsr ,nd ,lroimy\ tssr
<br />;";,- i2s E ;;,; ,V:
<br />uc.ulsurg)Nrade[x
<br />IIILAB]IIIQN
<br />I hcrehy ofirm undcr lcnoh, oa perjlrr rhar I !n licnsd undcr,rernioi orCh|tr.r9 (coihmRir8 with Sccrion ?(xll) oil)ivnion l
<br />of thi Busift\s and Ptuf.sions Codc, {ft my lkcnsc i in tull forcc and clitcl
<br />rclnzb
<br />_1.1q it (on,nc,or A6L
<br />CONIiIAIJ]IIONI.ENDINIj.&{jIN(I
<br />I h.rcbyulln u crNnihyoirrrjuryrl rrhcrcisrcon{rucii{)nLtulid!r8ci.ylorthclrrtunrunccollhc*nrklor*hkhrhi\Irrnirir
<br />i(nrcd (Sc. 1097-Civ. C )
<br />AITUCANfDI.q,INAUAN
<br />I hr$y afinn undcr |xuhy of ncijury onc of rhc tullowins dcclnrarion\
<br />D.n,liri()n Pcnnirs Asb.ios Nolilic{id Fcdcrrl RcSulirn)ns (Tnlc,1o. Plln6)
<br />Rcquircd latrcr ol Nurifi .dion
<br />l.cnrlyrl rlhc ltdcrrlR'!nhrion\ r.!iu,li'rg r\hcd,'\ r0Nnrlrr. norrffl'.$1. t, rlri( I'otc.r
<br />F!, -nr, 'n.r ,n.^",",,,na Jrrrl,cr nr,,l {,.,hr rhcrh,!. i',ro"mri,r1 is .or..r l lrcctu.oNplysrhrrrciyrrr(,trtr y
<br />ihnvc mnunRd nFIan, for m.nccrio! |urrl.\cs. , ^ /1
<br />Appricm,orAEnrsis*,urc Y' V^JLw-!/-
<br />p.m,* n.m.,prrn,,: V'mlhAu)/qkdu*1ql
<br />S.2q. r(
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsu lation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsu lation/Energy
<br />Drywall
<br />Brown Coal
<br />Itr'lasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL b/7/, // <g[)t6
<br />Certiticate of Occupancy
<br />Notes, Remarks, Elc.
<br />COMMENTS
<br />Ext./lnt. Lath
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