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BUILDING. INSPECTOR HECOHD
<br />SITE-WORK DATE tD/stG.COMMENTS OWNER BUILDIIR DELCARATION
<br />I h.rcby afll(n lndcr lcnalry of pcljury rhnr I um cicmpr lmm rhc ConrracnF l-iccny ljN lor rhc lnlbwing tur{.i (s& 70-ll 5
<br />ausi.css d Piofcssiotr c(ll.)r Any Ciry or G)unry shich Eqrnc\ i ltrn b .onsrucr. alic.. improvc. d.nmlish or Nnrn rny
<br />slruclurc. prhr ro ns nsunncc. ako rcquncs thc 0prlicn for su.h lrrmit ro filc. si8trcd nalcmnr thrt hco! shc n liccnscd ruisuo.r
<br />k, rhc pmvhio { ofrh. ConrE.ttr s Li.cnkd ljw (Chaprcr 9. C.nmcncii8 airh sccrn,n 7fiD olDivilion I ollhc Bus:ncs rtrd
<br />Pnr'cssionsC(trlc)orrhrrh.or\h.iscxcmprrhcofiomandrhchasi\f{trrhcrllcg.dcrcqrnr.Anyvi{r.rl]nofssrion7011 5hrnn,
<br />rpplicani iq a pcrmit subicc rhc lp|licant h acivilpcn0hyoinor n,clhm Iivc hundred dollaB (3500)
<br />l. 0s owmr of Ihc proFny. d nry cnrllorcs wnh wigc\ a\ rhcir \rlr ..iil).n\aridr, will do rh work .nd ih. stuluE is nol
<br />inlcnlcd orontrcd lo, slc (Sa 7Or4. Busincsr0 Pmfcssnns Codc Tlre Gnhocrois Ltcns ljw dcs nor !ppl, ro ro o*ner or
<br />rhc fnlp.ny wtb brilds or inlrmv$ rh.on. md sho des skh wolk himsclfor h.r{lfor rhtuulh hh or hft.qncn1Ployccs,
<br />poviJcd rh{r ru(h i'npmvenrnh ec ior inic'rlql or ofierqt for ule. li ho$arcr. rhc ttrilding or i,nprorcmnr i\ rtd *irhin om )tr
<br />oi con{'lction. rhc owrcr Buitcr will h.vc th. burdcn of poving rhnr tE or shc dd mr huild or inprovc lhc l)n)t'sly for rhc luryN o,
<br />l. rsowrcroilhcpmp.rly- anciclu\nrlyconlrlclin8 wilh lccnscdc. mclorslocon(rucl rhc prc]ccr (Scc. ?0.r4. Bu\inc*
<br />0Dd PmrNsi.'n(bd.: ThConti.rofs Li.cnsc Lrwdo.\ dor rplrly k, mowidof l)n,F yehohuildsornnprovcslhcrmtr.
<br />and gho conrmcG iot su.n rrercls uilh a Co acrodn lrcn$d Nrsurntlo rhc O)nrracru s Licos li*)
<br />lanrcrc r|n undrr Sc.r
<br />D.r. Oqn.r wonxrns,rtrnrtnNi,aTroN-
<br />I}&CI.ABAIIQN
<br />I h.icby arfiid lndcr ncDlry oi Frj!ry on. .l rhe lbllosi.g dcclaJarnt.s:
<br />I hrv.6nl will miorlh n CcnifElrc ofCon\enrro Sclf'lnsurc for wo!kc6' .ory)..\Ii6n. B povid.d f.r by Sc.lion 1700 ofrhc
<br />lllttr Codc,l'orrhc Frrbrmoncc olrhc work ior whicn thc pcnnil is hsucd
<br />_l h.!c ond will mlinhnr wor*cm compcns.riotr insuran..,,s mquicdbyScclion3?00ofrhcL.tnrCodc.lo.rlErrfomEncro,
<br />thc uork for which this lcnnit is isstoi My BorlcB comrcnsar ion insumrcc caFicr ad lblicy nunrb€r ecl
<br />- AD? Aa{a-isp.^r< c
<br />/ oq1 o327-_7q c_A ..r,.", ?/r lrI
<br />I.cnilirl r in rh. !.rlornBncc ,)t tlr *o* f.r *h ich rhi! llmir is issucd.I \lirllnor cnfk'!rnypL^on nr.try r trrcr
<br />$ ,\btf,...f, sxhj.rr b rhc "$rtot .o.r!.n\dridr h*\olCJlin)6ir. id +N rlrrill should hc.otrF \uhFcr rorhc
<br />so*.ri .u rFi\ari( pioei{.i\ or Sc.rn,n :lT0O of rh. trhtr Codc. l dhLl, fitrth*irh .onfly wrth rh.s fnvision\
<br />W/\RNINC l.rilurc b {curc workcn c.mpcn\rri{D covcrl8c i\ urlrslnl. sn,l \hrll srh}cr rn.mpk,ycr b rinriml |tmhts rtrd
<br />(i!il finc\ uf nr onc hrndr.d rhor\and dollrrs (Sl ni{r r) rtu c.n ol c.tr,trtrsrrion. Ji !.\ r{ frovtrlcd l'tr rhc
<br />Sc.rtrri 1076.frhc Lhtr l-':sl
<br />I}EqI,AEAIIO!
<br />I hcrcbr rmm unds D.nallrotperjlrr llul I a'n liansd undcr pmvision ofChaprcr 9 (c-mntncins wirh Sccrion 7UD) ofDivision.l
<br />of rhc Bnsincss .nd Polcsions Codc, orn my licc.sc h in tull Iorc . clt'N'.
<br />Cto q8r,t1 7
<br />tt I t t
<br />AIIUCANLI]ECI.AAAIrcN
<br />I hod,y lrrm undcr Fnohy or pcr.iu.y oE of rhc fdlo$ir8 d(hral ion\:
<br />Dcnblition Pcnnits.Asbcstos Norinc ion r{dcrrlRcsulalionr( litlc 4,0, P0n6)
<br />-Rcquncd
<br />L{cr or Nnifi c.liotr
<br />I crdifyrhJr rl'c lcdsalrcgtrl&otr\ rcgdi',9 r\ltno\ r.rnNi rrc mr xptli(nlrl. r, rh \ t,n,i(r
<br />-l
<br />ccnifyrhar I hate rcad rhn.pnlicorion ad natc drar th. alnvc inrbrnuiiotr iscotr(l I lsN tr.omply sirhrllciry ad Counry
<br />or.linrNcs rnd Sratc LawsELrinsro buiklins connrudion. n ncEby rurhori- rcn crnratiles oa rhn Cny anrr Coumy t .nrd uF,n rhc
<br />ih,trr nrIi,nird t)n]lInI li]'
<br />Appli.nnl or,\I$t Sign"l0
<br />o..L4N, UAe /<4<aVt
<br />tlB/a
<br />Set Backs
<br />Erection Pads
<br />Sublloor/Vent/l nsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.+<p)fr t4 //44A )
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL t /<12fCD
<br />Certif icate of Oc cupancy
<br />Notes, Remarks, Etc
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />t7
<br />caNflBl]sul)ll.rNDali-dli.ENl:I
<br />I hc,chy lmuundcr rEolh y oi pcrjuly rhar rhqc G a consrrucrion bndi.s aa.ncy ror rhc pcrlanturrc.l rhd sor* lor slrich lhivrrnrii is
<br />h\ucd (sN. l(I)7. civ. c )
<br />tJ tu1",- . NJ 'F
<br />Lchdd\ Addrcsr:
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