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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS oWNDR AUILDER DEI,CARATION <br />Ihcrchyrllir undcr pcnllty {,f pcrlury rh.r I rN crcnrnl lnnn rlr Conrmcros l-icctrlc l.as f{{ rhc nnhqirE rr!{rn lstc7lrll5 <br />8u\incs rnd Pnncsion Codc) Any Ciry ot Counry shirh rlluircs I lclnil h cotritu.r. !tl.r. imptos. &nxnnh '{ Nfri Jnv <br />{rudu'c. pifft, it\ irsurtrcc. llso re{tuiEr rhc rlpli.dnr lnr such P.tmil lo ntx sirtr.d {dcmtrl lhar htoi dt n liccnEd Pu^uoni <br />lo rhc [ovisions ol lhc Contr.r.f\ Licctrscd l-rw (Challcr 9. ConnncncnrB wnh Sccri'n ?flD or Divhion ] of rh' Busnx\\ rnd <br />Psncs\ions Codc) or !har trorshc iscxc rrr rhcrctrommd rhc basis lor rhc alLscd cx.trrprion Anvviollri{'nofsc.rion703l56vany <br />rmli.adr ror a !.nnir subjc.lsrh. rpplicanr k, r.ivillrcnrhyol trol rrrhrtr nlc hundrcd dolhr (3500) <br />-1, <br />u\ owftr or rh. po|cny. or my .'npk,Jt s wir h wn8cs as thcn $b cotrlI.nsrr t'n. will do lhc *ork a l rh. stutuE i\ mi <br />inrcMcd or ofltrcd tor elc (Sd 7(x4. Busirc$ rnd Pmr'csnrns Codcr Th. Conkaclor's t-iccns uw docs nor 3prlv ro d owncr o{ <br />nE pRrr*ny who bxilds or impmv€s rhcED. and $ho do.s skh wu* himseltor hcntlfor rhmuSh hn or hcr Dwn cmPlovccs. <br />trcvidcd rhor such inDrowrnk d fr, imcndcd or offcErd lor sh lt howcw. rhc buildi.s or iqrokmnr ie $ld wilhir .m se <br />olLlnlplctk,n, lhc Owrr Builds sill hrlt rhc hnrdcnolPoving rh hc or rlE dil ml build or iq'mrc rhc l)n,pciy for rh. puqn\c o, <br />I.doencrofthcnroFcny,!'n.x.lu\i!clrconhdins*irhliccn{d.ontt.!)nk'co{tudrhcpoiccl(Ss.7In4Bu$n.$ <br />md L\ofssi)n Codc Th.conracloisLiccnscLisdmsnorryPlytoano*rcrorrrol.dlwhobuildroridprovcsrhclcon. <br />rtrd who conrmcr s lor slch pdirts wirh r ct,trrrck,(n li.cnkd pr (urnr r. I hc Conrractn\ Li.cnsc Liw). <br />l () <br />I hcrcby allirnundcr pcnahrorr.rjury.nc ollhc lnllo*in8 dalarrri(,n\: <br />I htrvc st will minllin a Ccnificarc ol con*.r ro S€ltlnsurc r(n sorkcn compctrsation. as lmvidcd io, tv Ser tun r7(x) llhc <br />Ijhor Codc, Ior rhc ,rrfonMmc ol rhc *oik for siich I hc Fn.il i\ is\u.d <br />-lhavcaftl <br />*illmrnnrin wortc^ .oflPcncarnn, insuraN., rs rcqoircd brS.crn lT(Xrol thc Lal,or Cod..lir rhc lEfrm nccol <br />rltr sort nlr {lrich rhi\ lcnnir is h\usl. My workc^ $nrFns.rion imui0ncc mri.r rtrd Flicy numhcr m: <br />Pol'.vNumlEr <br />- <br />-lccnily <br />rhrt inrlf, p.rfoiatrmc oflhc sork for *hi.h rhis prirnil is issu.d l drallflot c.Ulovun!lcN)n in onvnunmr <br />$ s b bcom subjd b lhc uorkcK compcnsation h's otCrlirornin. Md a8rcc rhlr iil should tEcnnrc subFl b rhc <br />qortcrl compcnrliior prcvhbn\ or Scdion :lT0O of rhc Lnhn Crdc, l sh l. lorlh*irh co Dly w ilh lhos pDli\n,ns <br />WARNINGT Ftrilurc ro *crc *orko\ (rnpctrsdiotr co$mgc is unla*ful. lnd \hall suhicr .n cmrlole. ro dmi'd ,.mlrics .nd <br />rlI{^ri,] (1,'11.tr\ lSll)o.iirl)r. i, xd(l1iotr I rhc.o{ ol co rtrtr{riotr. dtrnriscs r\ nrcvillcd lnt lhc <br />tg , <br />I hcahr rftDnndd t'ctrrltyofpcduy rhd I i li€tr*d undcr Inovirion orCh4rc,9 (c.nr nENi"g $ h sr.notr 7(x[)).r l)'\hitn ] <br />ol lhc Busimssand Pmf.ss ns Code- nrl myliccn\c is in full lnr( .ml cilccr <br />CONSTRIX]TIoN LFNDINE AI]FN(IY <br />IltEhyrlft'nundcrlctrrltyoI!.rjuryrhrrrhcrciii.otr{rucrioD[n(linga8c.yl.rrhcncr&rnunoorrh.workfor*hi.hrhNttnnri1 <br />nsucd (sN. :1097. ci!. c.). <br />knls'\ Ad.!r.ic <br />- <br />AIIUIANLDECLi IXAIION <br />l hcrcby limundrr ttrn lryolperjuryom orrhc rolloq Sdcclarllions <br />lxmolirio! Pcrnrir\ As}fnos Nolilic0li0n FcdcrJl Rcslhrnnrs (Tirlc.l0. l'rn6) <br />ll.qu 'rd l.tcrol Nor'llr[i,n] <br />l.cnllyth.r lhc lcd.rul rclxld k)n1 e8ulin8 ashc(os rctrk'valrrc tror.Pnlic!t lc nr rhis fbicr <br />-l.srityrhd <br />I hrvc readrhh iplli.arn,hMdial.thar rh..k,vc i nfornhrion ir .onNr. I lgre ro co Ply wnh rllCi <br />hy rurh)rnc rcl)lcscnt0tivc\.frhk Cirt.nd (o!nroi{lnxn..\ an!LSr c Irs\ rc1 ir! ri hull(lltrg.o <br />xb.vc nrcnti(inc(l proFny tur <br />ADplir nt 0r,\g$lsiBnrltr ir6, <br />Set Backs <br />Forms/Sleel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Sublloor/Vent/l nsulation <br />Rool Sheathinq <br />Shear Wall <br />Framinq <br />lnsulation/Eneroy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Ivlasonry <br />T-Bar <br />Handicap Req. <br />Deputv Final Report <br />Enqineer Final Report <br />FINAL T/i4s >\ 8a <br />Certif icate of Occupancy <br />Notes, Remarks, Etc. <br />Pool Fence <br />Flood Zone Certif. <br />----+---