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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER Bt]II,DER DELCARATION
<br />I hcrchy xrfinn uMc! lr.nrlry r)i p.rjury th l on cxcmo lior llE ConrrrnF t-i..ns. b* lbt rhe roln,sing rcisn (Scc 70.ll 5
<br />au{incs\ .' Pof.$i.i Codc) ny City or Counr, which rcqunc\ r pcrnrir b .otrnrud. alrcr. lnrPn,vc, dcnFlish or EIrn r,
<br />rrn'.rurc. rrioro irs n\uatrc. rlso rcquncslhc il)Pliclnr for su.h Ptnnn ro fik tr sisncd \ldcitnr rh hcot shc is li...\cd lursurtrr
<br />lt (hd provnions olir Conr8.trtr\ Li..nscd tjw (Chrprd 9. coarnLrrins *irh s.criotr 7uD oi Dilnbn I ofrh. Bu\ints 3nd
<br />Profc$ionsCodc)orrholhcor\h. it.rcm!r rlrcrclroih Md rhcbrsil lor rhcallcscd cx..yliotr Aryviolari,,nofsc.tior70ll 5htrnv
<br />applic! lnr tr permi! suhj.rc rh. apph.nn o .rvrl,[nlkyolnor Rtrcrhrn fit huidrcddollars(lsin).
<br />L a\ owncr ol rhc ln,p.ny. or
<br />'ny
<br />c plo)cc. $irh qr8$ us (hct solc compcn\rrbn. will Jo rlk Bork dil rhc (erft i 'rri.rcndcd orollcrcd for elc (S( ?O14- Busincs rnd Profcst'nr Codcr Thc Cotrtr.nn r l,i.cnsc l:*docs or.PPlyIo3no*ncror
<br />rh. pDp.ny who huildsor irprorcs rh.Ryr. mislxl dm! such so* hnnsclforhc^cli nrrhrouph his or hcr o*n cn{loyc.\.
<br />tr.vidod rh.r su.h rpn,vcor.rs xrc nor inicftl.d or.ntd ktr eh ll h.qc\xi rhr buildiiE .r inllnn rNnr is sold wiihinom rt
<br />ol.o Dbrnr. r OwNr BuilJcr rill h$c thc hrdcn ol'pmvi,E rhr hcorsh.did trorbuiUor iDP(x! rlf pmFny for rh. PurF&of
<br />ff4[r. *"",-.i,r," p"1*ny. an crctu\ir]ylofirdi',s trirh r(cn\cir.oNacrr h con{ru.r rh. F!r..r rscc 7o.1.r. Rulno$
<br />rnd Pn)fcssi(rrcodc: Thc conrxcror's l-iccn\r t-r* docs nor,pflyk, rn ostrrt of Dr)|Fdy sho hildsor inp tsrhcrcotr
<br />rnd whD contklsn s'ch rr+crs $irh a Con@.ttr(\, li.cns.d pu^r nrr)rhcCl r&ror'! Lirans. l-r* )
<br />lrnrc\cnpl undcrSdbn-
<br />,,,,. I itq(,tLurYi ,,",,",*
<br />I hcrohy alfirnr uNlr pcmlly oI lE,jury onc of rlE followin8 dslarart,ns
<br />I htrvc drdwill nrinrah 0 Ccn iaEal. ol Con*nr ro Sel{ lnsure l'or sorkdt ..nEnsrrion.as pmvidcd fu hyS..rion 37mof lhc
<br />hh.r Cod., ror rhc p.rrormRc oflhe work for wntt rhc Frmil n issocd
<br />-l
<br />hrvc rnd $ill.uinhin $o!hcr' .o'qFns,rbn nNxh..c. a( rcquitcd bySc.rion ST00 orrhc lrhitr Codu, forrhc t'c.t lnEncc ol
<br />rhc *ork for uhich rhh Frmir i\ isfl.rt. M, wu*ds .omp(nsrton insurlEe .oricr ard Flicy nrnhrr ml
<br />lLll-n,r,,r,, .,r'.
<br />'*4,-rdn!(.1rhc
<br />tr.lk n{ qhtrh lhis n fln I is i\\u.J- I \hrll or. rtkJy.nyNr$tr rnoDy'olnncrirr\rohoirE{'hrc.rtrirhcwitrlt^'ujml]c'Ni,tnL,L\rolcalituhir,rtrdrgNcrh.rillsh.lldhccomubjccrt,rhr
<br />$orkcri corDcnsarion pn,!i\n'n\.fSrcli.i.1700 ufrhc htxtr Cdlc.l \hrll. i,fh$ilh conrpl, wirh rlx'\8 pi.vnn \.
<br />WARNIN(; Frihrc b $nrc sorkc6'conDcnsrri(r.ovcrr8c i\ unuBhl nnd shrll suhjdr dr crDloycr lo oirninnl NDlric\ rnd
<br />civil ,inc\ u! ii orc hr {lrcd rh.us.nd dollrN (Sl(Xl.fiX)). r rddnion r. rhe cosl oi compcn\rri( , dmrgcs ls Provid.d br lhc
<br />Srcrn,n.1076 of rhc lf,titrCdd., i .rc\ a.d rtr.rmy'tli{l
<br />'!. i t\ ( 2t t{
<br />^r,p,iun,:
<br />K-
<br />I hcr.hyxlitor uDdcr p.nrlr) oiprrjury rhd I rn,lic(f{d rtrtls pnria ,rofChi cr 9(.onnrncinp $irh S&rbn 7([0) ol l)ilision ]
<br />uf rhc llrsircss d PnncsiorsColc,n nryliccD\c i! i'r lulll,n.rrndcic.r
<br />IONJ'IB!,&IIANI,ENDING.AGENJ:I
<br />IhcrchyalfinnundcrFn{ltyolFrju.ylhirrhqchacon(ruclionkninsnEc..trorrh.p(n.rnnnccofrhcsorlnnshi.hrhi\J{nii\
<br />i*u.d (Scc 109?. Civ.C.).
<br />Artuc NfDlict a&trlJN
<br />I h.r'by fllnn uMs $nrlty ol |crjury onc olllrc lnllosnr8 nshrdbnr
<br />DcnxrirDn Pcnnirs Asbcnos Notincdionl'cdcral Rcsuh'bns('lnt.u)-Pd6)
<br />Rcqulrcd trxcr of Nolifi corion
<br />_l crniry rhd rhc Ldctul rcerh..ns rcSddnrg osh.nos rnrvnlnrc nol {ntli.Jblc n, lhis p^Iccr
<br />l[(ccrlilyrh.rI lu\c rclr rhislpplicarion0 l\rtrrcrhlrrhcah)vci',ronturnriscomrIi8,.rroconulywnhalr(ryIndcoutrry
<br />ordhnN.s0nd Shrc h*s El inarobuildinscon(rucrn,n-uxilrcr.hyruirktrizcr.pr.s.trrrlv.sorrhisCilymdCounryrocnrcru[x,nrhc
<br />trhov. r.rnnrd pn)Nny lar fis|cdiotr furtx){s oa
<br />-l h*m
<br />L
<br />I -'l
<br />(--
<br />Appliunl {r Axcnl Sirn,luc
<br />""-'r""
<br />,",,",rn",,,{
<br />DaieTn -iVL-)
<br />Sel Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Ener gv
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />lVlasonry
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Cefiif .
<br />FINAL a 7/z;t /t/a,ar'rh /t7
<br />Certilicate ol Occupancy 7 / '
<br />Notes, Remarks, Etc.
<br />-+
<br />Erection Pads
<br />Pool Fence
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