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BUILDING- INSPECTOR RECOBD
<br />SITE-WORK DATE IDiSIG.COMMENTS OWN$R BUILDIiR DELCAIIATION
<br />I hcrcby rffinn uMrr p.trllty ol r{ury lhal I i cxc'npr rmm rhc Cookact'^ Lkd* Law lor rh. lollo$ir8 rclv (Sc.70:ll5r
<br />Ausimss 3 Pron$ion Cdc): An, Cir) or Counr, which r.alunc\ , FYmi' ro connrud. altcr imprurc, d.drnh r RNn y
<br />rlrudurc. prior k' ils issuanc.- rl\o EquiN rh. +pli.a ntr rx.hltnnn tu fibr sisncd nalcftnr rhar h.orthc t li.cnscJ !n uanr I
<br />h rhc F)visbns or rhc Contruclois Licenscd Law (Chaptcr 9- Conmtn i'r8 wirh scctiotr 7ux) oi Divtion.] oirh. Busiics rid
<br />l,rufcs\i,,ns Codc)orrhur hcorshc ncr.mpr rhcr.fi.nrind rhc hr\ir hrrhc ilh8cd crcmflion AnyriohrnrnofScdionTl)ll5hynnyl
<br />applicanr f'rs p.rmir iubr..lsihc aFtli.,nr ro a.ivill,cn,lryolmrrmrcth fivc hudrrd dollu\ ($5c{})
<br />-1.
<br />!s owner of lhc rmFnr. or my €nplor.cs wirh wagss rh.n r,lc .TNFnsarion. will do rh. work ad 'lr sulm t nol
<br />inr.nlcrl or on 6d ror sL (se.7o!4. Busincss atrd Pnfcssn'ns Cutc: l]lc Co.rd.i(tr\ Lhcns. tis docs ml a,,/y ro 3. o{mr ot
<br />rhc pmFnt rrx, hilds or inpmks rh.Nn. dld qho drs ssh qor* hiNcltor hcEcllor rhDo8h hk or hcr .wn.qrloyccs.
<br />proridcd rhor such inrloEmoh d mr inrc.& or ollcrd for $k I( h)wctq. rhc huildiDs or irq,mrern! h okl *irhin onc )m
<br />olc.'itL'i,n. tlr owtur But s siu htrrc l1r bur&noflmvir8 rhllhcor shcdil n hoild or irrpDE fic PmPf,ny for rhc lJlqbt or
<br />I. r\ owncr of rlE Uoprny. an cxclus ivcly conrr!.ri'rg sirh li.ctr{d co r.tr( h coNnrr rhc Projcd lscc 7tl14, Buws
<br />x] hDGs\ion Conc ,IhcCofi&ttr s Li.cnsc L0w,nrs ior atflylo rtrosncr olItropcnysho huild\ or nnrrovcs lhcrc.n.
<br />rtrd who.onmcrlorsuchprojcchsirh0Contracror(9licctrlcdpursurrhrhcconlr..roisLi.cnscLas)
<br />I Ncxcnu nDdcr s..tio
<br />lvaBNlB.LrallfliNlarloN
<br />oEcl .BlIIl!)!
<br />I h$.hy rfiilmundcr pcmlry oi rrjury o.c olrl.ir hlk qirs d..hrdnnn
<br />l hdw ..d * ill Eintai. a CcniaEatc ol Consnl lo Sclf- h\urc nr s.rkcs .onlrnsd ion. $ pmlided i.r br s..rn'. ]?UO of r hc
<br />bhor c.dc. ror thc p$follm.c ol lhc work tu whi.h rhc Fnnil is ilsucd
<br />_l hivcrnd !ill mannanr uork.6 coqri\lrn insur tr.c. n\ rquircd hy S.crnrn .l?(x) of rhc Lh.r Cbdc. lbr rhe Pri{{m]rcc .l
<br />rh. *ork fu Nhichrhi p.mir is i*kd M! wor*.rr .onr|rnsdrim in\trutre.xricr ul B,li.t mmh.r dc
<br />Policy Nunrh.r:-DrDncs:
<br />l.rnlli rhd ii rhc |xrlnftn.Ncofrhc work lor whichrhis pcrmir i\ is\u.d. ! shrll.or cnlroyanypc6on inlny!tunncr
<br />$ !s h hcco'm subjcd ro rhc $o'lnr onp.nsrn,n I ss ofcrlifnnir. i.d qrcc rhir ill \horld tf,coft subj.{ o lhc
<br />$orlcr comp.n\rriontmvisio.solsc.rionlT(Dolrhc hhtr (idc.l dull lonhwnhc.,nplysirhrhotpnlnion\
<br />WARNING: Failurc to sccure vorkcr' ompcnslrtnr $vcracc is rila*hil, rnd shrll $icr m cmrlorr ro oi. ndl ,rndrB iftl
<br />.ivil nn.i up b otrc huudrcd th.usad dolhN ($lm.rxxr). in r dili,,r k,rht.on orco.rtc.srrion. damagcs ar puvid.d r(tr rhc
<br />S..rn -1016ofrhc tibor Codc. inlcrcn d rltormy s lics
<br />Dlrer Appli@nl:
<br />UCENIELCANIIAqIA8
<br />DEII.AXAIION
<br />I hcrcb, ofitD utr.lc, I]cnulr, orr.'jtryrhrr I m li.cn$d undcr Jrrcvnn'n ofChoprcr 9 (onmn.ing snh scclion 7m0l ofDivisn,n 3
<br />of !h. Busims"nn PmfcsionsCodc. and mv liccnsc is i. fxll tur.! atrd cliicl
<br />CONEIAIJCIIONIIIDINC.&AENS
<br />I hcrcl,y affirm rnacr Fn ryolFrjuryrh3l rhcrcisaconslrucli,tr lcndinEaEeoc! nn'h. pcrrorrurc ofthcwolk for shich rhi\ Frnir ir
<br />issucd (Sec 109?. Civ C )
<br />ASfIICANLDEIIAMIIOII
<br />IrEEt,allin utrdcr,rn,lryorlErjuryorcolrhcfollowinEdccl !rions:
<br />Dc'Bnirion Pcrmic Asbcsro! Ndrin.drn Fcdfial Rceulntidr\ (Iillc 10. P0n6)
<br />-Rcquircd
<br />lrllcr of Norilicaft ,n
<br />l.c rililhrl rlN li(lorLrcgulxri,,n\ rcga inI \h.(orrc tr)rrl c ior tfl,li.rhic ti rht Pn,rc.r
<br />-lccnity
<br />rh lharcrcadrhisrpfli.rridrtnxllarcthrtlltrti'*n'tunn tr i\cotrftr lr8rer..on{lyNithnllCiryrndCoutrr,
<br />nnliiancc\ridsL.lrwsnlaritrgrobuildirgcotrnn,clion.Mlhcrcbynulh,ncrcprc{.rriv.solrhBCilyandCoutrryrt,circruFn'rhc
<br />bov. nrtrlioncd p.ot ,1y for insFcl ion rury)xcs.
<br />AoDli. l or AqenlSirn.lrr€
<br />l'c.nrile na0r(pnnl):
<br />Set Backs
<br />Forms/Steeli Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsu lation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />A
<br />FINAL l0-zs-1f,k.l/btl
<br />Certiticate of Occu an
<br />Noles, Remarks, Etc
<br />UFER Ground
<br />L.ndd\ N.m.
<br />I
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