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BUILDING- INSPECTOB RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUII,DNR DELCARATION
<br />I hcr.by alfirn und.r r.ialry (,f pcrjory rhlr L cx.nl f6'n thr Conh.ntrf l-kcn{ tiw for rhc following rcrsor (Se70315
<br />Businc$ .d Pflntssion Codc)r Any any or Connry which rcquncs I F.mn ro c.nsfld. alrcr. imlrovc. dcmohh or rcFt .'ny
<br />strucrurc. rior ro ns ksuancc.,lh rcquncsihcappli.ifl rbr such Fnnir ro filc { si8ncd sIltc"Enr lhor hcor she t liccnEd pursusnr
<br />t, rhc pr,vi\i,n\ ofrhc Conrra.tu\ l,i.cn\cd lns (Chryrer 9. Conmedcin! wirh sc.iion 7Ix)0 ot Divhii,n I ol rhj Bu\inc$,nd
<br />Pn,fc$n sCodc)orrhd hcorsh. i\.x.mpr rhtrckoDmd rh3bnsi\ for rhc rlLgcd.xc'nnrio. Anyvi.ldionofSlrrimT03l5byiny
<br />lppli.rnllorap.rnilsubjc.hthc.!pli.!.lx).civilpcnakroln.rn,clhrtrnvchutrdrcddollrr($5m)
<br />I. i\ .wncrofrh.pn)tcrry.,trnrlc rd.ycc\ wirh tr.3cr.\ rlidr{,lccotrrpcnslid,. *illdo thcsork thc{to.turo i\ ior
<br />idcnd.d orollircd fr slc(Sc..7tE4, au\ntcs\ d Pnra\si. s Gxlc Th.(idrrd\Lid \c IrwJoc\not rttlyn' r owtrnol
<br />rhc |mi|rny ah, hlil& or i',pn,v.(hcftrr, .'rl *t() ih{\ uh s.* hNrllor hc^clior rhrough ht o' hc' o*n c'ntloycc\.
<br />lmvidcd nnr su.h inuovcnrnh rrc nor inlcndcd or ollcrcd lor sb It: hntcEr. llL hliklin8 o. inlPnM'm nv,klw hi,ro c)tr
<br />ol co tkrn'n. rh. O*ncr Bui[tcr *ill hzk rtE hddcn ol poving rlBr tr or \hc n id nor hu'kl or i'ryRM rhc ln,IMy lnr r]r t)uil!'{ ol
<br />L n(.wncrofrhc l)(,lrny. .m cxclu(ivcly conrrrlir8 wirh liccnsd conrra.ronroconntucrrhc pn+.! (s& ?(!1,1. Burinc$
<br />aid ft,ta\inr Codc: 1 hd Cofi!.ttr1 1-i.. s. tjw d(f,. tror .ptly b
<br />"n
<br />owrcr ol roFny who builds or inrpiovcs lhcrcon.
<br />and uho .otrrEcls tb! such preids *ilh r Co.tftr.n9 li.c.sen Nnu,nr lo rh. Co racrois l-iccnsc l.iw)
<br />,.incrcmfl xndcr Serio
<br />]van6D&t-l:wfENllr()x
<br />DECLA.BAII()N
<br />I h.rcby rffinn undo ll.nnlrrofFrjurrom nfthr talhqnr8 dNhhriois
<br />tlrrlc&d*illnunnriraCcilicarc.fConscrbS.lfl'rsrrdntrworkcs.omFN.tiotr..sflovnhdforhySecrion:]7(*)oirhe
<br />litxn C{nlc, tufic ll.rturnrNc ol ihc sork rq*l,ichrhc pcrlnir h nsucl
<br />lhov.and rillm0inlrin workcr{ compcisatior nruratrcc..s rcqlncd hy S(t ion 3?00 ol rh. litxr Codc, fff rhc Isroituncc or
<br />thc Nork lo. which lhn pci, l is hsEd Myuorkcr' comr.nerio. insuiuncc cadcr ud policy iu'nbd d.l
<br />P.li.yNunrbDr: Lrlircs
<br />-l
<br />cenirr rhar itr rhe pcrto,u,c. orrhc so* tr *hich rhi{ Pe nrir is tsu.{.I rhrll e cnDluy rny r.notr n' any nn'nrcr
<br />s .sb kl'..om subi! tu rh. wolkcrs' comFhsarnrn Ls\orcrlirnnir, rtrd.8rcc rld ifl should bcqn'r uhicl x, rlt
<br />sorkcs.otrD.ns,rio.povisionsofsc.notr1700olrh.kborCdc.Ish.ll.iodh*irhconplywilhrhospmvision\
<br />m dtrlPl.Jri b diriml |tmlric\ md
<br />civil fiDes u,, ro onc hundr.d thou\rnd dollm lSl00.000)nrn. dr'n8cs ,s providd ,or lhc
<br />S)'.lg i' c'rdxndxt rh-v ! lt.\
<br />I hcrcbt rfllr runJ.rlrnrlrtolt).rjrryrhlr I r t lilrtr{d uM$lnovi\ir olChrptcr9
<br />of rhc Br\irc\\and PorcsionrCodc. &d ny lkcn* i\ in tullli,rcc mn cfti{r
<br />n! *lrh Scclion 7(Xx)r ofDirni{in l
<br />l,*.5:24'I( "*"."-,7t>
<br />raluBucuqxLDNuuclc[Ng
<br />I h.rcht lmnnund.r Fiakyorp.rjury rhdr rh.rc h a.onsd.ri,n lcndinB 08cn.y for rhc rcrlbrmancc ofrhc *ort tor which rhis tsmir i\
<br />issucd (Sc. .1097-Civ C )
<br />AIPIICINLDIICLAAAB)N
<br />! lmb, rllinn utul.r tcnnllt ol Frjury oft ol rh. f{'lk vine d.clrrur n,n\
<br />Drnx'ljri(r l,cnnjh Arb.no\ Norifi.arnrn FcJcml RcArhrtnN l'f[b.10, P"n6)
<br />Rrq n d lrndrnfNorifi.ar01
<br />l.c,rifyrh,rrh.ladcrdrcEulrrionsrcBardire.str{o(rc ryrl ia nor {',rli.ahlc ro rhn nrojNr
<br />-l.rlilylfial
<br />I hrrc !c!d rhn applicorbnntslircthar rhcrh)vc nuri,r i\co'rccr l xgr(ki.u llllywirhrllCily.ndC.utrry
<br />ordinrnccs lnd Srarc l.a$srcl$ingro hui , aurhori.c rcprclcnrrrivc\ ofrhir Ciryffd Coriry to crr.r uF{ rlk
<br />.txnt nrnrioncd pn,rudy ftr n$lr.r
<br />Apnlicnnt o. A,ttnl Signaluft
<br />a
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsulation
<br />Roof Sheathino aln lg 1 MVett v>
<br />Shear Wall t't t U/
<br />Framing
<br />lns u lation/E ne roy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlasonry
<br />Pool Fence
<br />Handic ap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />I )
<br />FINAL a /ft//// t /71/18/2'//fi -Cert iticate of Occupancy
<br />Notes Remarks, Etc
<br />Forms/Steel/Holdowns
<br />T-Bar
<br />Flood Zone Certif .
<br />WAnNING I'rihtrc k' KUE workol compcnsaliflr ovcrr8c is unhwlul. lnd +xll
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