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BUILDING- INSPECTOR RECOBD
<br />SITE.WORK DATE ID/SIG.COMMENTS O$Nf, R AUILDER DELCARATION
<br />I hcr.by rrfinn u cr p.nalry of pc.jury rhnr I un.rc'n|, fo'n rhc Conlrcck'F Ltccns hw lor rb.lallowing rcN'n (Scc.70.11.5
<br />alsincss ,nd Ptufcssio. Cdc) Any Ciry or Cou.ry qhich R.quncs a pcrnir h .on{tud. ahcr. imtrovc. dcmlnh or (n,t rtr!
<br />{ru.luE. prior h its isuoncc, de ruquncs lhc aplli.anr i'or such psni r. fiLa si8n d $arcm.l rhdr hco. shc n liccnscd PUNlnr
<br />r. rhc ,svisiDns .r rh. Conlncroas Llccnsd L.w (Chanr.r 9. Con rcmins wirh Sccri.n 7ffn or Dilisn,n 3 oflhc Busincs lnd
<br />ProacrsionsCodc)orrhar hcor shc l\.icmnr rh.rcfronard rh.brsis frtr rhc,llcgcdcxcry)tLotr AnyviollrionolSmri,rT0:ll 5byrny
<br />rmli.rnr rd dltrnir iubjc.N'h. rfplic!.r ro acivilpcnrltyol.or rmrclhan live hundBtdoll s(S5fi0.
<br />_1, !s owncr ol rhc l'oleny, .i
<br />'ny
<br />cmrl,ryc.s wilh wo!.s N rl[n erc corEnsalion. will do rhc work ud rh. nurm h mr
<br />icnJcn.roffcrcdrorslc(Scr0l.l.BlsimsrandPmlc$ionsCode:i'ieCnnrracroirLiccnsctr*do$60rrrplyh.no*ncrol
<br />lhc pmrEn, who builds or itrrpr)Es rlEbi. ntul wk, dtr\ \tch $ort hins.lror h.*clror rl&uBh ht or hd osncnlnk,y.c\.
<br />pturidcd rhar such impov.mnkmmr inrcnd.d orolrctod for slc ll howNcr. rh. huildirt or iDpnrcEnr isn,klwirhin. c,td
<br />ofon{lcr,.rh.OwerBuittdwillhrv.rhburddnofprovingrhdhc.rsh.dil.olt{ihoriq)row6epnrpdyfffrltPu{r{.f
<br />I.$owncrolrhctopcn!.0Dcxclusivellconrrrrinswirhliccnrdcontrtrsh.on{,drhrftuj.cr(Sc.7Lq.1.Btr\inLS
<br />n lhli:ask n Codc -l hc Conhclf s Liccn\c t-rw ,nE\ Dor rrplt (, nn or rcr o f froprn y vho $uild\ or i'nprcvc\ rhcrcon,
<br />aM qho .ont *larsu.hpmjcclsrvilhoo)ntrucrorG)liccnscd,Nrsutrnltirhc(i,ntr.kt'\l-i.cDs.l-rw).
<br />_l a6.&npr undcr Sert,n . B. & P.C. fo lhis rer\on.
<br />DrI€ o*n .
<br />YQBKE&:.!AUf,EISAIAN
<br />DECL$AUqX
<br />I hcr.hy rlltrn und$ rcnrlry of Nlury o,rc of thc lollosirE dcclff .ti.ns
<br />I hnvc md * ill roinrrin r Ccni6.nr. of C.nscnr b Scll l'isur. titr workch con,rNxrirn,. \ prtNid.d nr hrSccriotr.17{},roilhc
<br />Iihor C'qlc.lor rh.Ii.rr'or,me otrl[ work f(r which rh. Pcrn,ir ir ilsuL{
<br />I hrlc rd willr.nniin qorkcrs comp.nslln,n in\uruncc, rs rcrlltcd hrS..rntri l?0)ofrhc LnhorGrlc. fitr rhc P.rLmnct of
<br />pcmrir is i$ocd Nlysorkcre conl,cn\llion in\u Dcc cnri.r rid li)licy iur rr sc}\t.\
<br />co 1U4.
<br />-l
<br />enilylnar ir rhc F.rfornsnccolrhc worl f.r uhi.h rhh P-rmn k issucd.l shall nor cnDLyanllc^.n h nnynrnncr
<br />q, s r. bc.om subl.d to rh. wo*crs ompcnsirion lo*s ot CrliiorniD. nn{i a8toc rh irI should beonE \ubjEr l"rh
<br />wolk.rJ.omp.nsarion,,rovhionsofScdionlTfi)olrhclitiorCodc.lshrll.rodhRirh.onDlyqilhlhosDrovision{
<br />WARNINC: Failurc ft, scurc NU c^ (,npcn\arbn covcra8d is !trhwlul Md shrll sul,Ft an chploycr h dnrinrlFmlrics d
<br />", ",'liis" ti $,)Ululi...1 "'
<br />I hcohy nnn trM$ trtrillyolpcrjur) lhul I anr liccrcd I)nn i\n,n ol Chrtrr' 9(.otrnnctr.irg silI S..rion TlxX)) olDn \i',' ]
<br />ol rh. Ru\i'rcs rnJ Proli\\nnN Cdc. M ry li..is. s h rrLl tunr u .llrci
<br />-G ^^,n 0 4
<br />6UrZU rc
<br />{0NglBll(:Illlltu:luNcncExlI
<br />I hcrchy rtfirn und.r f,cn,hyorlcaury rh.r rhcrc is a.o.nflcrotr hodinE uscicy r{tr ih. Frrornrd.c ollhe rvork for *hich rhi\ Frnir ir
<br />ksled lsc..3(l,7- Civ C.)
<br />ATILICANLIECLASAIION
<br />I ho$y rliinn undcr ncnolry oincrjtrry onc otrhe lollowiis dcclnrarhns:
<br />Dcnmlirion Pc nn*Asbcsros Nori,iclrion Fcdcrul Rcaulxrions lTirl. t0. PM6l
<br />Rcquircd Lcttcr olNolilicalion
<br />dffi::",idrrrlrclrln.o s r+n'dot r\l)cno',. trrrl e ml rpt,li.xblc ro
<br />I ll8re ro comply wirh rll Cily ,trd Counlyir.n lhl\xmlirxrii,,rrxt{rcrhrril[r
<br />oidinrn.cs.trdShrctiwsrclorin8robuildingcon{tu.r hcrtby aurb,rrc r.prc{ntlrivc\ ,,f rh Cny and Counry ro cnrc uI,n rtr
<br />rl\\r n'. ri,trrd r)rrlnrry ni in\)erri,tr,
<br />Apdic,nl or l\s6(sisnnlutu
<br />Prmrile mnE (I,rint)l h
<br />,,.alljG 0 t, lii18
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loorivenVl nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq :[6r
<br />ln s u latio n/E ne rqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It4asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL /u/;t 36-$
<br />Certilicate of Occupancy
<br />Notes, Remarks, Etc.
<br />Erection Pads
<br />i/?*/6
<br />Lcndcl\ N[nc:
<br />-
<br />L(h
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