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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE COMMENTS
<br />Set Backs
<br />Forms/Steeli Holdowns
<br />Erection Pads
<br />UFER Ground \
<br />SLAB Floor
<br />Sublloor/VenVl nsu lation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lt/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Beq.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />/A
<br />FINAL K-7*lv
<br />Certilicate of Occu pancy
<br />Notes, Remarks, Etc
<br />_)
<br />OWNDR BUII,DER DELCARATION
<br />I hcrcby artrn u6dcr p.ntrlry oi pcrjury rhdl I am cxcnr,)l imm the Conlk-roF Lierr ljs ror rhc rollowirr8 rca$. (Scc.703l 5
<br />Busincs .nd Proic$ion Codc) Any Cit, or Counly whi(n lcqutcs ! p.rnrir b .o.ndcl, 0lrcr. iintmvc. dcmlhh or el)air any
<br />(rucrurc, prior ro ils issulicc, nho tuqui'csrhd dupli.nnr for su.h,icrnir lo lilc, signcd stutcmtrl lhal hcorshc h iicenscd frrflnr
<br />ro rhc rmlisions olrr* Contnclols Liccnsed Llu (Ch.rr.r 9. Commrcinc unh sc.ln,n 7o0o.f Ditision I ol thc Blsincs rnd
<br />Pntc$ions Codc) or thrl hcorsh. ncicmpr rhcEfrom and rhc l,!si n, rh. Ic8.dcrcmprion. AnyviolotionolScclioiT(r.ll5hysnt
<br />lprlicanr tor aF,nrir suhjecrs rhc applicdt t, r.ivilpcnllryornor morcrhnn 6vc hundrcd dollrs(S5(x))y'-,t-
<br />(4r n* ""n","r,* prnr"nl.nrn) cnnlnlEs q h tra8cs!slhcir an.con{tnsrion. willdo rrr effkaM rhc {trru h n,r
<br />icdLn or or.rd f.r slc (Sd 7044. Bxsifts nnd Pmfcsrionr C.dc Thc Contuclol s l-iccnsc lj* docs nor +ply r. Nn owmr ol
<br />lhc pmlicny {ho builds or nrDrevcs rhcre( aod who dmr such $oll hins.lfor hcrelror [tuxgh hn r hcr owtr cnDloyecs.
<br />toridcd (hnr $uch impoEftms e ft, ir cndcd or oficto{ hr eL. It k,*cver- rlr ttrilain8 or iq,rorcntnr is v,U *irhin oi. !t-
<br />oI on{'krion. thc Or'lcr Buil:Lr will h8lt rh. bordcn of ntuvina rhzr h. .r shc dd tror build or irpmlc lhc tmfiy lor rhc purll,y ol
<br />l. r\ .q ncr ol rhc rnpcn y, am cxclusivcl! ..trtrdin8 snh ln c {d .ontdn( h connru.r thc pr+ct ( Scc 7(YJ. B!!N*
<br />.rd P a\sion C.dc ThcConlndors l-iccnsc l-r* (locs nnr 0tplyro,nolncrotpn)rcdy wl'n, huilds.r inr[.ic\ rhcr.otr.
<br />and sho ..nrrrt ln su.h ptujc.h wlh r An tu.kdg l,ccnsd nr$anr lorhc(intNkn \ l-iccnsc l- $).
<br />Ixnr.\.Dr rtul.r S..rirX* tf l1 l iY A
<br />I hfchyalln utrdcr lcnrlrtol tf,r.turyotrcof rhc f(,lloNing c.!&.1idrs
<br />Ihvc rdsilltuinrrinaCcnifi.nrcofConscnrtusclf.l0surcfrtrworkcN'corpcnsarn'n.r\ p(ridc{lf.rrysccrion:17(x).lrhc
<br />ljbor Gx,c.lor lhc lErl'ormrmc oirh. *ork fr *hich rhc pcrmir is is\u.d.
<br />I hrlc rnd sillnlrinrri. qorkai comNtrsariotr insurrncc. rs Equircd h, Sc.r ion :l?01) nf rhc tjbor Codc. in thc Pcdonumc ol
<br />rhc workrorwhi.hrht p.rnrir is hsu.d Myuorkcn c.'nn nsarion inslmnc.crdcriJ rx,licy nun$.r &c
<br />.-/ 4L."n'ry,r,, .,r" n"*",rDncc nlrhc trnrl ,,r shi.h lhi\ p.rnrir i\ ir{rt, I shsll n.r ontloy rny lcGon in any tunncr' <i-a' rr l".-'m.uhE.r r" rhc $.rkr^ qnnp. .Jrr{ liwr orCrlilnrnir. nnd.src h.r if l \hould trcom subjccr b ihc
<br />*ork.ri co'nndtr\rrion pnri\n,nrofS..ri.n 37(I)otthc Lrhtr Codc.I shrll. fonh*ilh cohnly sirh rho{ ptuli\i.nr
<br />WARNIN(; F.ilurc lo KUrc wolkcri corrpensllion covcra-sc n unhsrul. md sh ll suhF.r m cnll]]o]tr lo rinitul ,lcmlii.\ nid
<br />civll firc( ur ro onc nundrcd rh.u\$d dolhi\ rsl0().0(x)). in irn,i {o rhc doi of.otrDcnsalior. dinEscs u\ p(,vidcd for th.
<br />Scdi lr)74 oirhc l;]t,or Codc. iircrc{ rnd altnmy \ nc\
<br />{"' zf tt l'x --rk "-,
<br />I hcrcl,y atfirm oidc, FnahyorFrjury th,l I an li.cnsd undcr pmvisnlr olchnoer 9{conurcnciis wirh Sc.rion 7000) ofDiviion:l
<br />.f lhc Busincs and P,ofesions Cod..,ni nyli.cn{ h in rullroftctdcffccl.
<br />C(INSTRTICT(IN LENI)IN(; ACENC{
<br />I h.rby,ftirmutulcr p.nallyorNrjurylhoi rhqc hiconstruclion knditrsascn.ylorrh.rc nnmnccorrhcqo lor shich rhis Fflnir i\
<br />nsucd (Scc 109?. Ci! C )
<br />AIIUCAILDICLAAAII}N
<br />I bft$y Hfinn undcr Fn,xy of Frjury onc olll[ folbqnrB d{lffrlions
<br />Dcnnlirion Pcrnils Asherror Norificn!nrn Fcdcirl R.grlrrn,n\ (Tnh{. Pan6)
<br />-Rcqutcd
<br />Lcrrcr ol Norifi ctrri)n
<br />I cMiryrh.r rhc Ldcrd rcgul0lioN rcBedin8.\bcnosrc {,v!l s'c nor l0 i.dhh torhistmjccl.
<br />.<,$,/rlLl (i r ry rh,r I h!'c rcad rhtr arrlrrrn,n &l d d. rhrr rhc dh,ve inlonulion G (otrccl I s8re r. 6n'lly wnh ill Cny and County
<br />-ordinatr(s 'nd Srlrc L!w.mLrinE,n hu,ld,Ils .onqtu.rtr , ald h.rcbt rhoizcrcprcsenlatirc!ofrhilCir,rdCountyloctrloulonlh.
<br />.hovc nEdioncd fotl.ny hr jns
<br />Applic,nl or,{[enl sifldfurc
<br />P.mire n,m. (p\,6:c-<) YE'r,/
<br />y", -fu2lrv
<br />DAArfr
<br />ID/SIG.
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