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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE tD/stG.COMMENTS O!INIiR BUILDIiR DELCARA'TION
<br />I hcrehy atfirm ufrld pctulry or rc4ury rhar I am cxcmt'l f,or. rhc Contrh$ Li.cnsc L!$ lor lhc li)lk,*in8 rc,$n (Scc 70ll5
<br />Busincs nid Pn,i.sion Cclcl: An, Ciry or Colnr, which rcqxircs . Frnnt ro consldcr. rlr.r. improvc. dcflnlhh or rcPlt any
<br />slfl.turc. prior nr irs hsuancc, lho rcqunctrhc !!tli.,nr r(tr su.I pcmnr lo filc ! sis cd {,rc f,ht lhlllEor shc is liccn€d pu*u,
<br />b rhc px,vi\i(,n\ .rirL Conraclois Lienscd Laq (Chaprer 9. Co nkmlnE uirh Sc.rion rO(N) nr Divi\n,n I of rhc Busin.$ lnd
<br />Pn,fu$ions CoJc)orrhnl hcorshc i\crcmfrrh.rcfm md rh. ttrtsis nn rhc rlhgcd erchnrion. A.ylioldio olSccrtr?0115by0ny
<br />apllicairrfftrp.flnir sublc.k lhc oDflicnnr lo!.i!ilrcnrltyolnot dodrhu rivc huDdtcd dollln(t5m)
<br />l. rs oRncr of Ihc pn,rrny- or ny .nplolh\ sirh wr!c\ ns Ihr ir $1. co ,p.t\ar nJn. qill do rlE strk ffn rlE {r*h i. m!
<br />icndcdoron..cdror\rlc(sNro4-,r.Busincss.ndt'ioiesrbnsCodc'I'hcCok..roisLicctrscl]wdocsnoramlyhnno*ncroi
<br />rhc pmlfny qho build\ .r n\mrcs lho mr aBl who d{f,s \uch Mrrl hi rcll or Mnell or lhroush hi\ ot hcr .tr tr crPloyccs.
<br />Drornhd lhat such imll)knrnr\ r. nor i, cndcd or ofltNl r.r *i. ll how.vc.. rh. hiunE or iflPnNur isq'rl*irhinotu)ta,
<br />ofc.q)krFtr. rtf,Owncr Build.r $illhavc rhc hftlcn ofptuvi.g rhdr h( or shc,lil tror huiklor itr{tr)rc rhe Pmfny for rhc IUrIiM of
<br />-1.
<br />as owmr.f rhc I,rol.nr. rncx.lusnrlycnnridin! Nirh lic.nscd contnct*\ ro con{rucr rlr poiccr (S( 7Ol4.l}u{ncs
<br />rnd Pn)t$sionCodc: Thc Co lrrctr's l-iccnsc l-dsd.c\noi aPrlyro otrown.r ofp(,Pc twh(,builds.rimpovc\rh.r..n.
<br />and *ho d,nrracrs iitr ru.h t'mi.N qilh rConlacto(s)liccnscd purranr t,rhccotrhcnx s l-icctr{ llwr
<br />I rn cxctrrpr !trlcr Srri,u ll & P( larrhi\ rcr{nl
<br />Doler O*ner:
<br />IVoRXFRS CONT}aNSA1 ION
<br />DICI.A.8trIII]!
<br />I hcrcby rfllnn utrdcr,rcnrliyof pcrjuryon. orrh. tullowi'E d..ltrilions:
<br />I h.vc .nd will iuiruin a Ccn ifrdr. or C.tr*trr ro sclr lnsurc ,n wo,ke6 conlcnsrion.0s lDvidcd lbrh,Sccrion 17mof thc
<br />lixtr Gxlc. ldi rh. ,cfonMncc oi rhc sor( aor which rhc P$nil h issucd
<br />I hN ..d w ill moinlain *qkcrr' romPcnsdhn insunurc. as rcquircd h, Sccr i(,n l7m of lhc Lahor Codc- tu rh. |Erfonufrc of
<br />rhc *.lk lorwhichthis nennlr is issucd Mywork.rJ.onlttrs.li ln{rumc cri$ ! policynumh.rucu..r'
<br />N,,,,,b",, - Lt \,/ e {on'L f,1ro 't / ralr t
<br />-l
<br />ccnify lhnt in thc F.|('rtuncc ofrhc work lor whth lhis permir is tsx.d. I \hall nor cmploy rny pc^on in an, mlnrcr
<br />$ .s tr troE subj.ct ro rhc Nortcn compcn'iion hws ofC.lif.ari( and {3c rhar ifI rh.uld hcconE suh]cci t, rh.
<br />workcE .onrpn.ntion l)lovtn]ns o, sccri.n :17(x) or lhc trbr C.dc. I shlll. tnhwirh .onuy *ilh rhosc Imvision(
<br />WARNINC: FliluE ro scm wortcn ompcns.lion covm8c 's untustul, trtrtl \hrll hr{r rn cmnlo)cr r. niminrl PcEhh\ and
<br />!nil rn'c, un n, onc hund,.d rh.u\.rd dnlhh rllur.r)trqf,n '"lJtri,'n n' rnc !^! nf c.mn€n\r'cn. dr u8c' r\ Fr,1d.'l fitr rhc
<br />Sc.riotr l()T6olrhc Lhr A^lc Dktoqand hflEv's l!(
<br />,",., \ r/etll1 ^*Y a.,,,.'qt -/. ILICINSLDCON'[R ("I(}R
<br />IIECIA8AIION
<br />I hcrll,yain undcr F.dlry oftcrru.y lh.r I !m liccnsl undct Prcvi\id of Chrytr 9($nrmnciig wirl Sc.!hn l00O) ofDivtirn:l
<br />nr rh. Btrsin.s trnd Pmfcsionsc('dc. rnd mvli.cnsc is in frll lire a clfrr
<br />a-L q4fZo?
<br />cj tz4tt {9t g" :et,t,":
<br />g)NSIB]JI:IIAT.LI;NIIINII1iIN.CI
<br />I hcrhyafii, utr rr Fnrlryoipcrjury rlurthcr i !.oi{fl.rFi btrdirg rgcrcy lor rhc P.tfoilrur.c .lrhc work Lr which lhi\ Fr mir h
<br />ksucd (Sec :ll)97, Civ c.)
<br />APPLICANT DE(]I.ARATI(TN
<br />l lmhyrfinnundcrp.trtrXyof ncrruryoncol lhc lnlb*n,! dmlrr n N
<br />Dcnnrlirhn Pcrn,ir\ A\tE{o\ Norili.dion Ftdc,ul Rcslldtrn\ (Tiilc 40, Prn6)
<br />llcqrircd Lcncr of Noriliciri,rr
<br />l.crtilyrhot rhc n,lcrxlrolulnrois r.!dding ashc(ijs rcnFvtrl lrc nor q,drablc to lnh pmrc.!
<br />I ccnnyrhlr I halc rc rhi!nptli.drn rd nrrc rhar rhcnbvc iDl,r' in iscodccr Iosreloco'nPlyairhallCirv!trdCoDnrv
<br />odn$ncrs and Surc La*s rL inerobuildinBconnddion.! herct'yaurhoriucerrcscnrllrcsofrhhCnyrndCounrvroenrqrPonrtr
<br />;;;:*_'::ffi#'ih-;1
<br />,,^u* * ",rn^,, / 14, n:^ ( +l
<br />qfeil rs
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Brown Coal
<br />lvlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certif.
<br />FINAL X /.?,,//e "*O--)
<br />Certificate ol Occupanc\i ' /
<br />Notes, Remarks, Etc.
<br />Subf loor/VenVl nsu lation
<br />Ext./lnt. Lath
<br />t nds s Add,c*
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