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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE tD/stG.COMMENTS OIYNER BUIT,t}I][ DELCARiIIoN
<br />I hcEby amrnr undd ,cn.lly of pc,jury rhar I im crcn' lrcm rhc (nntmcr.s Li.cn* law r{x rhe lbllowi.S Bu$n (s& 7011.5
<br />Busincsr nnd ltofcssn,n Codc) Atry Cny or G)unry whi.h rcquirc\ , J).rni lo .onnrucr. nlrcr, improvc. dcnnlish nr rnzn any
<br />srrucrurc. p orlo ns nsuoncc. oho rciutcs rhc atrlicatrr ior such lErmir ro lilc a sirncd sllrcmnr rhlr h.oi $. is li.ctr{d pu6u,trr
<br />h rh. F,visionr ofrr. Conr.rct.as Liccn*d tz* (Chaflcr 9, Condc..in! *nh s.crion ?fixl of Divniotr 3 ollhc Business ind
<br />P$r.$n,ns Codc)orrhd hcorsh. is.x.nu rhcEftonEnd
<br />'h.bnsi!
<br />tur rh.,llc8ci rx.mption AtryviohtionofSati'n703l5hruy
<br />nn!1ic.nl ror rrcnnil sublcctsih. !!flicant Io rcivilI].nrlryornornbrclh0tr fi!c hundrcd dolhn (S5l)O)
<br />lr,l. l)sn(r
<br />ItlBlillllli:(l2utlNsArlor
<br />I)lClzI-BilIlllN
<br />I hcr.hy xilnmunl.r pctrr (yolprrtury om ol rtu,nl1o$n,! d..Lrrrri{,r:
<br />lhalcr wilinL'inriinrC.nifi.rrcofCosc r)sclflnsrrrlitrw.rkc^'.otrrttrtrs.rnnr.rilrovidcdturhysccrnnr:17(x)olrh.
<br />l-rborConc.lorrhcncrrornunccotrhc*odnrshichrhcp.rmir i\ns&d
<br />I hNc trdEiltnri rir workcrl..rnncnsdnr nNurrncc..s rcqnircdbySc.rion.lTol)ofrhcl-r1'orO)do.forrhcncrloan ccof
<br />'hc
<br />sork tu*hich rhh!.nnn is nsucd Myworkcrs co
<br />cI t-/A
<br />I.cnrryrh ir thc NrtunMncc ol lhc wort Inr wh ich lhn pcrmil is hsrcd. I shall nor cdrloy any pdk inrnyflmncr
<br />{ ax ro bcconE suhject kr th. workcF clnpcnslrn,n hqa ol Cllihrniu. ,nd nsto. rhrr rr I should tuonE subiccl ro rhc
<br />*orkc^ .ompcnsarionpr.visi,)nsolSccrion.lT(x)otrh.hbor I \h,ll. fonhanh.onply snh rho$ lovhions
<br />W,\RNIN(; n'ilu'r t) \r.u'r \orkr'\ (a r|{lNdirnr !trhstul. rtrd \1 11 {i6,rcl cmpkDu h .rnniMl Ftrrhf,r n
<br />civil fi.c\ uI h otrc hundtud rk)u*trd d.llJrs rSlUl,UX rion b thc co( or coDp€nsario.. dan,gcs as providcd for thc
<br />S(rirm:1016 ol rlr t-rtxtr(iFlc. i'irrc{ dd rndtu
<br />7-1-/ k
<br />I hcr.hyxlllrrund.r|.frlryol lujLnr- rhxr I x, l.c tn)!isio ol ( hnprc' 9(conncncrE sirh Sccrion Tlnx)) of t),! no .l
<br />.l rhc Ausinc$ lnd Prora$ions c{dc. ud m, licens n in tull lore
<br />0,{81>7
<br />7-4 tL
<br />I hcrcby nr'tum undq Dcn{lryofpcrjuryrhar rhcrc h a d
<br />i$ucd (Scc 1097. Civ C ).
<br />nding{ri.y for rhcpcrf.nrtrrc oi rhc $.rl lbrshichrhlsr^-rn,ir i\
<br />APPLTANIDESAXATTN
<br />I herc$y !finn under !.nrll, ol l]c ju!, onc olrhc r'ollouiig dcclnrarion\:
<br />Dcnbl n'n Pcirnir\ A\b.{o! Norificrriofl Fcdcfll RcSul.rnrns (_I Ic 40. Pun6)
<br />1..
<br />\rhai rh. reddsl rcgolrrions rSdfnB ,sbc{os r.mrd .e nor 0r icablc b rhn ,mlsl
<br />I !trh! rvc nnbrmarion is.omcr L8re ro Luhply wirh nll Cny lnd G,unry
<br />ion.rndhcrcbraurhtrizctoprc{.rdriv.sof rhi\Cny {Counlylocnrcru'x,nrhcind SI.rc Lassrcllllins ro hu
<br />trrnftd pn)Itny tu,NF.lirrr
<br />o^.,. 7-
<br />x
<br />q-&'
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVl nsulation
<br />Roof Sheathi ng '/'iz-16 Jalcl a drl
<br />Shear Wall
<br />Framing
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ir/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />FINAL ?y'4/!c :N*(
<br />Certilicate ot Occu pancy
<br />Notes, Remarks, Etc.
<br />-f
<br />Erection Pads
<br />_1. as owmr .r rhc prcFny. o ny cmployss vith wrBcr as rh.n $t omDcNrl ion. *ill do lbc strk a.d rlE srtu1m i\ nor
<br />inredcn o, oflcrcd for vlc (Sa ?U4, Busincs snd Profc$ions Codc: Thc ConrEcktr\ Liccn* hw docs nol ,pply to an oprcr nf
<br />lhe pmrcny wk) buikis m imrmlcs thcNn- ald uln des srch qork him$llor hcrsllor rhmugh hk or h.r own.mFloyccs.
<br />Fovid.d rhar srch impmkGnk m mr im.nLd oi oilcrdl for slc. ll howw. rhc huilding or inlmEm n st wnhin om )ra
<br />of con{,lction. lfu Owmr BuiHs will horc rhc la(len oi pmlin8 rhor lE or snc did ml buiB or impow tir ln,Fny rui rh. pnip.{ ol
<br />-1,
<br />!so*n rofthc pn p.dy. urtrcrctusivclyconrrdinS with li.cnscd coniructor ro.onsrruc' ric proirr (sc. ?O,r4. Bu\i[r*
<br />dnd A.li$i,tr Codc: Thc Conr,cktr r Liccnic L,w docr nor sptlyi(, m own.r orpolcrty sho builds or nnprovcs lhereoo.
<br />und who conrack Lr su.h pmjccls *ilh a Conrncto(O licc.scd l)U$lofl ro thc Conrrrcrols Liccn\e L!u)
<br />_l dcxcnry lndf s(lhn_.B &Pc larrhhr.dsotr.
<br />crtricr rnJ Ix,licy trdtr$rr rr
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