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BUILDING- INSPECTOR RECORD
<br />SITE-WORK ID/SIG.COMMENTS OWNER BUILI'ER DELCARATION
<br />I h.r.by afllr'n xnd.rt).nrlry ol p.llury rh l m cxcnfl rm'n rhc Cirnr&hrs' l-tcnsc tiw for rhc lbllowing rcasn (S(?0:ll5
<br />Bun.c$ . Pnicshn Codc) Ant Ciry or Counry ehich rcqutc{ a F,rnir ro con(rucr- llrer. impnNr. d.nrrkh ur mtEt any
<br />(rudurc. I'n.r ro ils issulncc. alh rcquncs rhc atpliclnl for su.h pcrmi lo nk ! sirkd sarcftm rhd h.or shc i( li.cntd pusuan(
<br />ro lhc ln,visi(,ns orrtE conkrcror's Licen*d tjw lchaprcr 9. Co,nmcncnrs wirh Scclion 70OO ol Divhion I ol rhc susn'c\s,nd r
<br />P.ot$tunsCodc)orth.lheorshciscx.nDrlhcrcnomondlhch{sisturhcallcscdcxcflrprbn.Aiyvid i.nofsdri,trT0ll5hyany
<br />ryplicr nnipcn r subj(ls rhc lrplicanr ro ucivilpcnalryoinot nDrcrhai filc hundrcd d.llrs {S5{x)).
<br />I. r\ uwtrcr or rhr pmtEny. or nry cn{lo)rcs wlh wrEcs i\ rhcir $lc conDcnslion. w]l do lhe w.rlr ud rh. ntu1urc h tur
<br />i c8L\l oroltlrcdl'or\alc(SN.7&4,Br\itussandPn,iessioosCode:IhcCofin.ttrrLi.cnsuLrwdocsnol.!plytorno*Nrol
<br />rhcmrFny whr huilds or n{oEs rh.Bnr. aM who des $Eh so* hnn$llor hcrsclior rhrou8h hn o' hd owncnll)lovccs.
<br />pdvidcd rhar srch nnprorcrEnh an mr i cfrJdl or oficrcd ftr ek ll. h.w$cr. rhc huildin8 o. imnmvcm G skl *irhin onc )u
<br />ofcotrg)lclion. rh.Owncr Auilds willh3lc rhc burdcn ofpn,lins rhsr bc or +c did mr n{iu or itrpt,E rrr pmFnr lo lhc PurB)rof
<br />I. nwftr of rhc !hp.nt, an cr.tusivcly .ont rirB wnh Ii.cn{d ..nk((,^ h con(rud llE pmjccl (Sc 70$, Btr\i"cs
<br />xftl t\Drialir Codc ThcConrrkr's l,iccn\c Lnw docs nor,prlyk, xtrow cr.rpropc(!who huilds or i provcs rhcrcon.
<br />rtrd who .onr.r.ri ror suchpniccBwith,Conr.do(s) li.ctr*d FuNnnr ro thc ConrNrols t,iccne t,w)
<br />I rDcrcn, !id.r S..r 8 & PC.ldrhl{ rcrinr.
<br />lll8trE&l:C0MtEdSArA!
<br />DECIAXAIIQN
<br />I hccb, affirm ondd ,.oahy 6f Frjury oN or rhe following dNbnri.ns
<br />_l huve {ld s ill minhi. a Crnif*arc ot ct,n*nr b se lfinsud ror eork. conp.nsalion. $ tmvtcnforbySdio.l7mol'he
<br />L,bor Codc. for lhc ncrfornume oa rhc work lor sfiich lhc rcmii is nsed.
<br />I hN.,nd willnainrain work.rs comlEns0rio. insur,fte. $ r.qut d hySccriotr l?0Oollhc Llbor Codc. ror rhc pdf.rmn.c ol
<br />lhc wo,k for whi.h tbis pcrmil is irsucn. M,worlcK onEnsolion insuorcccurier sdFlicynun'6.i m:
<br />-l
<br />ccn iry rhor in lhc llcrlormncc oi rhc work tu qiich rhh n nnil i\ i\sucJ. I \hrll nor cn1pkJ! lny P.uon h !y nmnrcr
<br />$ b tf,co'm \!l,Fr k rh. *ork$( .omFn\rr ion ln*s of(]Jlif(riir !trd r8N rh.r ill \hoDld lEco,E rhJ.d ro rlr
<br />*orlcB confcnsrrion pn,virionsofSNri.tr:17(X)ofrhc hbr Crdc.I nnll. Ldhwilh conrply sirh Ihov In,vni(n(
<br />IVARNINC: loilurc to s!,c sorlcn co'npcnsdion corcB8. i\ unlaqlol. md \hrll suhjcct dr cnrployc! b d'niml Firkie\ md
<br />rivil lnrcs trI t)on. hun{lrrJ rhous nJ Jolh^ (Sllx).tx)t)), rdJiri(nr ro rlt..{ o
<br />H"**"'-**,-''"s(,n .rrrh, ,q r:4rc,kr.. ,rN{r
<br />"",", aL f tb LA C.
<br />IIIIIABAIIIJN
<br />I hcrcbyafilrnullccr FnalryofFrjuryrh l om liansd undcr lrcvhion .a Chlprcr 9 (commring wilh s(lk n Tuxr ) ol Divhion 3
<br />uf rhc arsims and Ptufcssionsdnic. and myliccns. is i,r full furcc.M cffccl
<br />@
<br />(!')NsrnucltoNliNDllc-aclill.l
<br />nnrcd lsc. .1097. Ci! C )
<br />AfIUqNLDESAAAIIAN
<br />I hctr$y.lirn undcr pcnalty ol!.rjuryonc orlhc n'lhwin8 dcch6r!'ns:
<br />Dc n irn)n Pcrnirs Asbenos Nor i6cdr im I'cdcralRc8ul ions (fnlc 40. Pun6)
<br />RcqunL{ tJ cr of Nolilicnlion
<br />_l ccniiyrhrr rhc tcdcrul rcsuhlnnr radn,! a\b.{o\r'tu,rrlm ior atflidblc r, rhi\ prol.cr
<br />-l..nifyrhsr
<br />I hrvc '.ad thh r,,Ilicrrionond{alcthd lhc 0trrc inlbrnnlion is cotrsr I asr lo odply wirh rll Ciry and Couniy
<br />onli'rJN\ rtr(lSr.r1.l r\s nlaritr! n) huild,nS ron('!rr aixl he[by rurrknrzc rc|ncsntalivcs oirhk Cilyrtrd Counrl I' cricr upotr rlr
<br />ltx,vc nrtrrio,rcd por.ny lor inspc.iion
<br />""-,,,"",n.",rnn,,, f AbA r;L U <* lf S
<br />8ilY
<br />Set Backs
<br />Forms/Steel/Holdowns r?,-rl, / t o / ,,. . ,i )
<br />Erection Pads ?l llt "/\/<l rU
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certil.
<br />FINAL 6(r.r\r.s
<br />Certiticate of Occupancy
<br />Notes, Remarks, Etc.
<br />DATE
<br />knd.lrAd&c$ _
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