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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG,COMMENTS OWNER BUII-OER DELCARATloN <br />I hcrchy amirn undcr pcnrlry ol Frju.y rhd I ar cxcmpl liorn rhc Gnhcros Licetrc ljw lor lic lbllowing rurq ls( 70.11 5 <br />Busiics a l P.of.sion Cdl.): Any Ciry or Counry *hich rcquircs a pcdir h .onnturr, alrcr. i'ntriov.. d.nslish or qrir rny <br />srn.rurc. flior ro irs $sun.c. rho rcqutcs tttr rapli.lnr lar ru.h triNr ro lrL. (i8md imcnrtrr th heor shc h lkn\cd pu^ulnr <br />r.rhctR,vnion\ofrhcConrrd.ttrsl-iccrdtr*lchlprcr9.ConinrncinCwirhSc.rir'7UX)ofDivniotr:loIrhcllusincssand <br />Phlisions Cod.)orrhrr h.orshc iscxcnpr rh.(nrdaftl rhcb:$is for rhc allcgcd cxcnrltiotr. Anyvn'ltltionofScdhoT0ll5hyrn! <br />rmlicrtrr ior a!..nrirsubiccrsrhc trfplica ro acivilpcnrxyoinor mo,crhan livc iundrcndollm (S500) <br />l,,s own.r .I lh. ln)l.ny. or nrt cnrdoy.cs with *d8csdt rhcir *rc.onf.n\.liotr, uiildo tltr work urd lhe stulm s nol <br />inrc cd or ollcmd lor qrlc rscc 7044. Businc$ and Piortrshi{ Codc: l h. Conrmctn s Ltcnsc l-r*.loc\ nor arpl, n, rn owNror <br />rh. ptuPcn, qho huilds or i'Jti()Rs rhcNn. aM who dG\ such s.'k hi'n\clt.r hcscll o hrough hn or hc. o*ncmpb!c.\, <br />Ix)lidcd rhrr \uch i'npmvcnM( m nor i c lcd or olfcrd f(tr !,lc Il lFmrcr. rhc huiklirg or nnpn'ErEn! ir sl{] Bnh onc Juu <br />olco DElbn.lhc Owrcr BuikLr sillhrrc rlt burdcn ol nmrirs ltur h. or shc dil mn huild or nlll,iolt rh. pnlFiy n, rhc N,Ix't ol <br />-l.r\.sncroirhcDrcNny.nncxcl$ivclycoDricrirruirhlrccoscnconrEcronhuonnru.rrh.Irr+.risc <br />7or.1, Bx.i"r$ <br />id h,fs\ini Cod.: I hc Contd(r'{ l-i.ctrsc t-.{ d(E\ ior xt,f ly r) rtr o*Dcr ol ftuNn, wlr. bu ild\ or irpr.!$ rhcrcotr. <br />rnJ *ho .onrnchinr{'.hnr!.cr\ wirhaConrrxcro(9 lic.n\cd pur\mnr t,ihc <br />I h.r.h!rllnDrun.l.r n tulryff |Irjuryoncolrl[foll(]*int,l.rIrr <br />I ha\t xlwill ntsinr0ir iCcnillcrrcofCon\cd roS.laln rc lar workcr'compcnsdion. rs prcvidcd fo.byS(rn,n lTlroofrhc <br />tihr Co{c. for rhc p.rtonnan..ofrh. wor* foi whi.hrhc Fnnir h n\ucd <br />lhrvcrndwillnritrloirworkcrrcompcns.liorinsrnD.c.r\.cqtrncdhyScdio.:l7lr)oilhclrh.'CoJ..ntrdt|trr(r un.cor <br />rhcqorklnrBni.hlnisncrDrilisissucdMyworkcrlconrFtrs.liotrnrurrrcccffii.rr E,lirynln'lf,rrc <br />Policy Numbcr:-E&itr <br />I..nif-rhi i'r rhd Frfonmn.cofrhc *ut f{n $hi.h rhi\ |xnni i\ n\kd.I drlltrrr ( rdoyinl |{rloD iri rryrufncr <br />n, rsro bcco c\ubl.crhrh.sorkd\(nnpctr\1ri,rrh$s.fCalintrtri.r.NnleEclhrlilInuLlh.on'c\!hj.!rrirlt <br />rvorkcrs.onr.trsrli r Drovisiotrs olScclion lT0ool rl'c Lrntr (irlc.l shill.lbnh*nhc, <br />\\'/\R\tN(i l.rinr. r, n.trr. lork. i.r <br />Dtrt( lgt'/3- <br />I hercbylitn undcr pcnJlry or ptrjury rhat I am li nr.vl\ion ofChlprr 9rc.nnk'xiig wirh Sr.rFtr 7(x)O) ol Divi\io l <br />.l rhc Busincss rnd Phf.s{nflsaodc, iM Nyliccnsc i{ in Iullr cc xlcllccr <br />CI}MiIA!1(JIO]I"LIiNDIN(;J(iINCI <br />I h.rcby lrtrnrundcr p.nrlry ortrrjury rh,r <br />'hdc <br />ir...tr{tu.ri)n hMing r8cmy for rhc pcrloflurEc otrhe sork lor *hi.h rhi\ pcrmir i\ <br />i\su.d rsrc ]m? Civ C I <br />aftllgaNr.l8ll atruoN <br />I[nbydim!nd.r prnrlry olPcrjtrry oic orrhc fo]k'*i'rg drclnrartrri\: <br />Dcmolirnr PcirnirsAnrsros N.rilicrri(nr tidcrnlRcruIli,ins (,ir1.40.I'anO <br />Rrqui'cd Lcrrd rr Nrr rl.i[ <br />I..difyrhar rhc fcJdrrl r.grllriotrs rgddlne rfr{o\ r.ik,!rl dc trorllPplicable ro rhis poFcl <br />I ccdiiyrh l hrvc rc.d rhilrpnl <br />odinaNcsand Stolc liws rcldiry ro <br />i.rli, r'rldrrc rh r lhc rli^. rrl;,,nrrnn) <br />Cirvrtrd CoDtrryr) ctrld utr r1r <br />rlxrr nrnri(,ncd !n)Ilo'rJ, l(f <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVlnsulation I <br />Roof Sheathinq 4 (ry-n h^crl 9)) <br />Shear Wall U \'\ <br />Fram in s <br />lnsu latio n/E ne rg y <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />lVlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif . <br />FINAL 'E1a Xvrreil 7-b) <br />Certif icate of Occupancy UI <br />Notes , Remarks, Etc. <br />I <br />/7