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BUILDING- INSPECTOR HECORD
<br />SITE.WORK DATE COMMENTS OWNER BUII.DI]R DEI-CARATIoN
<br />I hcr.by arfirn und.r Fnilry or Nrjury rh l mcxc.yr rtum 'h. Conadom l-ic.n\e L.w nx rhe {ollo*irE rdxv (s.c70ll5
<br />8u\nrs rlrl Prorcssion Codc) Any Cily or Courly Nhic| rcquires r ncmir k) consln'cr. alr.r. irriovr, d.nDlth .r toli.ir rny
<br />irruclurc- prtrro irs hN Ec. ai$ requircsllE lpl,licanl lor suchpcmilt,lil. r \igncd nrr.nic t rharhc.r shc is liccrscd lusu.nt
<br />to rhc pmvniotrs or rlt contrclols l-icctrscd ku (Ch0 f9. comnEncnr8 *irh Scdion Tl]O0 of Dietion:l oIrhc Busin.s and
<br />Itofc$ions Codc) or lhal hcorshc n cxcmrl rhcrcfrom Mn rhc h.sis f.rrh.alkrcdcrcmpri(,n Any vi(,hn,nolSccrirtr 70115 hylny
<br />rtpliclnt for a pcnnii xuhjck rhc applicani ro !cirilpcnrhyolnor mft rhai 6\. hui.lrcddollri!(3500)
<br />l. rs ow$.rrhc pnrFny, or [y c,nployes wnh wr8cs N rtrir slc .ompcnsulion. trillno rlr sork ldlrht {mrur t ,xn
<br />i c N or oli.rcd rd slc (Sa 704,r. Susincss lnd L\ofc$nnN Codc lhc C{n rxr'ois I -ic.n$ lr* d..s not lPlly lo an owncr .,
<br />rhc|n)lfny wh. huiklsor intsv$ rh.N . md who docs such wnk hirnsc for ltrhclfor rhmu8h ht orhcr own cnrploy.cs.
<br />pmvnlcdrhrr such inryokmnh arcnor inrcndcdoronbGl rtu{'h lf. ho*.!ci rhc h iklinA.r nnJ,ovdrnm h s,}d s,lhino'r rr
<br />of.olll)krion, rtrowncr Buitjcr will h!rc lhc horden or pmvinS llu! hc or nE dkl ml tn'ild or impn)k the In,Fdy r.dlr Futns or
<br />-l.asounc.olrhctqEny.rDcxclusiv.ly.onhctins$irhli.cnscdconrractn\nr.ln,ddcrrh.pirrd(s..7(11,1.Bun.csn l Ph,t*\inrCortc'lhcCo d.roa\t-iccnscLrwllocsiorrtplybtrr.wnnoltrolr.nyshohuildsorimrovcsrhcrcon.
<br />!trd who contNrs for suchprojccrswilh0Contrido(n licctrscd lusuMr ro lhc Conrrrlor\ t,iccnsc rjw)
<br />I rncxcmtr un{l.r Sc.rl
<br />Del. Osner
<br />IlaBNl&llralluiN$\1lo!
<br />DIiCLIBAIIO!
<br />I h.r.hy xfllrrnf,l$ Nnrlryoltr iu.!rn. l rhc lnlk,*i'rg tl(lr i,ns
<br />-lhrvc
<br />lrd w ill mirtrin a Ccn ilrorc oi C.nscnr to Scllltrsurc ior *orkeF convEnsdion. a\ ptuvid.d rdr byscclionlTmollhc
<br />tjh.r Codc. lor rhc rcformmc ol rhc sork rbr whth rh. Fnnir ( ksucd
<br />lhi\. rnd rillDinnJin sorlcri conip{n!nri{rn in\urnt. r\ rrqunsd b) Srcrtrtri:17(Xrorrhc Lrhor (iJd.. li)r rhe 0!rlonnrn..ol
<br />rl-. q.rl r r a,".1-,l- \ r,,r '. i.$'J Mj *{\c'.' n,n'ncr\' n r tr'.u':h.r.r'tr1 ,tr t.|'(L 1 tr'hfl rc,. .1zte fur'A,r,.rfunr,,,..?-rlq I
<br />-l.cnilyihrrnrrhc
<br />pcrlonmncc oarh. wolk nn{hichrhnn rnir k issucJ.I \hrll .rr lPloy.ny&r{r irr itrymrtrmr
<br />v) ff k,lr.onr suhrlrrhr rhc $.ik rJc.nrr.n\dnn lrus or Crlirnnin. ind a8rc.rhrril I lk)uld bcdotrf, \uhjc.rt,rh.
<br />work$( c.'nNtrsrr idr pturisbns .l Sc.riu :1700 of rhc trhr Codc. I sh.ll. li)niwil h .onrply s irh rhos p'.vi\i(rx.
<br />WARNINC liail[c n, surc worLcr\ cor,IcDsrrion.ovrrllc i\ unLslul. rid chillsrbjccl rfl cmnl()rcr ro dimtrrlncMlrics rnd
<br />civil fiics ut b oic l,u drdd rh.unrnd dolla^ (Slm.(XXr, i n,l irioi to rhc .o{ ol .oN|Ensdion- drnxr8c\ as frcvidcd lnr rh.
<br />Sc.rnnr:1076 of rlf, l,rbrC()dc. ir crcn.ftirn.nry \ la{r
<br />,,,,,,1'Tr^4
<br />DEIIiIIAII!]N
<br />Ihcrcbyafljrnrudcrlcnollyolt'crjuryrhtrlI0mlientonundcrtmrhionofChaplcrI(.oh'rtuin8wi'hs rbn?000)olDivision.l
<br />Df rh. Ausinc$ md PtufcsidrsCod.. dxl.1y lkcn* h in tullfucc 0rxl cftccl
<br />qHsTz
<br />)-734
<br />CONSIAUEIIONIEIDINC-&ADMI
<br />Incrcby affirmu cr pcnfllryolp.rjur, ihlrrhcrc n, $ndrucrhn hndins asrncy ntr rhc p.rr.rtukc olth. *ork lor which rni\ pcnni{ n
<br />isn.d (Scc 1097. Civ C ).
<br />AITLICANLDECIABAIIA!
<br />I h.i$y 0liim u.,ler rEn0lly olrcriury otrc orlhc lollowina dcclur.lions:
<br />txnrlirion P.irnirl sh.{os Norifi.driotr F.dcral RCEUldri.trs (Tirlc40. Pln6)
<br />Rcquir.dt ncr.lNoilrnti.n
<br />l.c'rilrrhrrl[li.dc'r]rcgtrhri,)n\rrlrnl U \hc(o\ilrno\rlIotrfrr|t)lnrflli)rhi.tn,i..r
<br />-lccnilyrhd
<br />ll}'vcrc thisapplic ion lnd rlalc rh$ rhe $o\c inr'orm$ion n conLrr lsgmroconrplywirhdllCityrndCoutrly
<br />odin.nccs and Sidc Lrws Elar ins to buildirec rc|nc\cntrncs oriht Ciryaiit Coutrrr ro cfrcr uE)n llr
<br />nlbvc rtrrnnrd I'nilf, tntr in(J)cdi(rr
<br />Aprlicnnl or Atrtrl Silontu 7D.rK
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVl nsulation
<br />Boof Sheathinq
<br />Shear Wall
<br />Fram ing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt- Lath
<br />Brown Coat
<br />Ir/asonry
<br />Pool Fence
<br />T-Bar
<br />Handi cap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil.
<br />FINAL 1t%tr5 ,..(4t@ I
<br />TCertif icate of Occu pancy
<br />Notes, Remarks, Etc.
<br />ID/SIG.
<br />Ln "r. ^d,t'.s
<br />I
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