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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COIVIMENTS OWNER AUILDIiR DELCAR T!ON <br />I hcrchy a(lrm undcr pcmlry of Frjury rhar I an crcmpr fm'n rhc Conr.trdor' l,iccnr ltrr' ror rh. ,olbsir8 mq}' (so 70ll 5 <br />Busir.(s (xi Pnnis\ion Codc): Any Cily.r Counly qhkh r.qut.r , pcnni! ro con{ru.!. rho. nn[ovc, dcmli\n or Flrt nny <br />(rucrurc. rntrro irs hsumcc. lho rcqutcs rhc trflliconr tor such lEnlir ro rllcasi-ncd (arcnEnr rhar hcorsh. ! lr.ikl nirulnr <br />h ihe pb!Gn,n\ of lhc a,na.roir Li.c.$d be (Chaprs 9. Comhrn ii8 qnh sc.liotr 70m oi Division I .f rhc Blsinc$ and <br />Pmlcssir sCodc)orrhar tEorshc hcrcmpt rhcruio rndrhc hmis for rhc rllcAcd crcnrlion AnyviolalionoaSccrknrT0.ll5l,yany <br />appli.llllturrlcnnilsuhjalsthcapllionrk'acivilnLmllyol'nolrmrclhrnfivcl't(ncddolla.s(!5(x)) <br />l. ,s osNr ol rhc tmncn y. or nry cmployccs wirh qi8cs !s 'lrir $lc snrFnei i.n- $ill do rlrc !ul( xl lhc nG*r@ i\ ton <br />inrc ol or o,Tc,cd for slc ( sa.7U44. Busine$ and Pr.tcsions Codc Thc Co .rctr\ Li..n* ljw does nor +pl, ti aD osncr ol <br />rh. l]()p.ny whohild\.rnn roh\rh.k)..rJklwhodo.ssuchworkhins.lforhcnclforrhrcu8hhisorhcrowncnd.ycc\. <br />nn,viJel rhrr such i'{r.rnrnc m rcr i cnd.<l ot ofiml ltr c c It hrwcver ihe htriuina or iq'rofrnnr is {)H Nirhin onc ,u <br />ol.omnlclion.ltr Owrcr Buildcr willhovc rhc huicn orDrovnE rhd hc or {hc did ml tuild or improu rhc pnrFny for rh. purF,r of <br />Lr\o$mrolihcp(,Jf,ny.m,rxclusivcly.oftrdi'r!nirhli..n\r{l.otrtr.rn\r!.otr{d.r(trttr,f.r(S.crUl1.Buin.\\ <br />Md l'rr)fr\\( Codr'lhcCoikd.tn'rLi.cnlrLrudoo\ orrtnlyh iowtrci olpr(itcrryNho lruild!.r irnllov.\ rhrrcor. <br />lnd \h. (x racr\l'orsuchnmFrswilha(ontacro(s)li.cnsc l'trnuanr r. rhr Ginr <br />Il[ <br />Ihrvcurlqilltrui rinaC.nifi.rcorCoiscirt,SclflnsorcntrworkcA'.omFNrrn[,(\lx)vidcdlnrhySccli,)n.]?(X)ofrhc <br />ljlxn O)dc. for ih. Frformance ol thc sork tu *hi.h thc pciinir ir n\ucd <br />I hrvc rnd willmtrn rnrlorters comprNrtion iisur.ncc. as rcquncd bySc(ion l?U)ol'lnc lihor Codc. tur rhc lrronmncc of <br />thc poik forNhichrht pcnn is issucd Myworkcn conrpc.si|ion insurrne caricr ud Fni., ntnrhcr m: <br />Crricr:- <br />_l.enify rhrr in rlE lErlon'rrc. ol rhc work in *hichrhi\ prrmn is ntu&I,I {hrll n.rc DloyuDya(non ir rnynunmr <br />s. rstu h.conr \uht .r l(, th. workcr oDpctrsrrir lws.rcrlironrir.nr{lo8rccrharill\houl(lbccom\ubjccrbrrf, <br />workcri onnrcnsrltunnNvirionroiSccrionl7{ otrhc Lalxtr Oxl.- I \hali. i,nhwirhcomnly wnhik,stn,vhidE <br />\IAR\t\(: r,,iL , ,,' ..,tr- q.rt \ ., ,rI. ,. it. , .rt n unh{1iil. ull] \hrll {rbid .,r ctrfloyrr ro lri'nirxl lf,mlri.\ i! <br />ion. danra8cs a\ [ovidcd f(tr lhr <br />ol'!.rjuryrhrr ! nr li.cnqlundcr proGi{)norChanrci9l.o nrf,ncnr! *i'h sNti{ 7(xxr ) oi Dirhi,nr l <br />PioLssio.sCodc. i nrylicctrsc is ir tullhr.c rnlcliccr <br />IOUEISSCIONIENDINGAGENCI <br />I hcftby alfirn trndcr Fndltyofr.rrury Ihrl rherc h ! mtrslrucrion lclldins rscmy lir rhc pcraortutuc olrh. w.rk id which <br />'hn Pcnnir n <br />nsucd (se -l(}l?. ci! c ) <br />afructttfDEct arlllu! <br />I lr'r$y rft u trrl.r Nnnlry olfcrlury oM ofrhc hllowirg dc.hrarions: <br />I)cnioliri,)n P.nnirs sh.{o\ Noiillcrri(). FcdcrrlRdBuidi('n\lTirlc 40 Pra6) <br />Rcquircd lxncr of Norili.atk <br />l.c(ili thll rhr rcdcal rcBuhlions rc8trdirB $hcslos Emxal.E nor mplicahh b rhn ptr,j.cr <br />-l <br />ccnlrylhd I htrvcrcad rhntlPplicrrionrld{ar.rhrr ihcxtrrc nnr i\.onc.r I gre h..nllllywirh {llCilyrnd Crunry <br />o.(lirrtrccs ann Shl. h*s <br />rhovc nrtrlotrcd [o$ny lar <br />APz/<Y*A <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsulation <br />Boof Sheathing <br />Shear Wall <br />Framinq <br />lnsulation/Ene rgy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />I/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Beport <br />Flood Zone Certif . <br />FINAL t0lAlfb )r\^tr <br />Certilicate of Occupancy <br />Notes, Remarks, Etc-