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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNEi BUILDER DELCARATTON
<br />I hcrcby aftrm undrr pcnrlry or pcijury rhrr I mcrcnrj, fio'n rhc Conrrros Liccn* l-rw r'or lhc nnbwine rcN)n l6cc70ll5
<br />Busincs lnd Pr.fc$ion Codcrr Any Cily or Counry *hich rcquir$ a pcm,ir ro La,n{tu.r. alrd. inPovc, dcnnni\h or rcpdt tny
<br />{rucrurc. pri{nro ir\ is\udce. al\o mqurc\ rh. 4pltrnr f{r skh Fnni tu lilc i \i!rcd nftmd nlJl hc or shc n li.ctrsd lu6ui nt.
<br />ro rhe lrovisions ofthc conhclols LiccnEd Li* (Ch!!rcr 9, ConnrEmins Nilh Seclion 7000 of Divi\i(,n :l ol rhc auri,rc$ rnd
<br />Pmlcsiotrs Codc ) or lhrl hcorshc iscicmpr lhcrcho and lhc brsh frlhc all.gcJ.xcnvrn,n Ant violnridrofsccrhn'70115 byany
<br />"priira fitrrp.rmirrul,r.c(ihrtrInli(rnrk,r.ivilr.nrhyofnr rtrc rhrn fivc hundrcd dolllis (J500)
<br />-1.
<br />as os mr of rhc trcIlcny. o, u! cmplorcc\ *nh w!8cs !s lhcir slc @ntlEnsrion. {ill do rtr work trxl trr nM@ is ml
<br />inrcd.n or ofcrcd ,o, *rk 1Sr.704,1, Busim$ and ftofcsions Cdc: Thc Conrmdor's Lkcns tj' dms nor appl, ro an osmr ol
<br />rhc pRrrcny who brilds or improrcs ricE,n. sJi *ho d{rs rrch wor* himsclfor h.r*lfor rhmuEh hh or hcr.qncmployecs.
<br />rov cd rhrl such impmrcmnr N rer i end.t or ollcrd for elc. l( hosrq. rhe brilting or ir{rcwftnr is $lt wirhin onc }E
<br />of.omphnnr,rtrOwmrAuihd$illturclh.bunLtrofthringrhdh.orshcdilmlbuiHorimpmrcrhcInslinytbrrn,rilnsol
<br />-1.
<br />asosncrofrhc ptu|xny. {mcrclusnclyconrrrirs qirh liccnscd contrctx h cotr{tuci rh. pR)j..i 1Sc.. ?(}14, Busir'c$
<br />dd Pn)r6\i,n Codc: Thc Cohii kr'(Licc scLn*docshor t)tlyt, rrowncr.iprolcny$ho huild\or nnpmlcsrh.r&i.
<br />lnd who o arch t !{chtrqccr\wirh u Conrrucro(9 liccnscd lururnr b rhc C(,ntacktr sl-i.cnsc Lrql
<br />-l
<br />rm cxcmrr undcr Sccrion
<br />]TI}BtrDII5:1:{'IIIENSAIIAN
<br />DIq,INAIION
<br />I hddhyrffirnrnd.rpcnalryorpcrjur!omofih.followinCd..l arions:
<br />I hah ml will nDinhin a Ccniarclrc ol Conscnr r. Scll-l trsurc lor workcr' comp.ns,rion. as potidcd for bt sNrion lTm oi thc
<br />lrtxJr Cdq for thc pcrindDm.ofrh. so* forwhich rh. lcrmir a issucd
<br />I h.trc.'.rd nrrlma .utr w.rlc,r !nrTcr\dFn 'n\urJn(r rcquircd by S(rion lT0Oofrh. lltrr Codc.lor th. pcrtoroumc ol
<br />rhc *ork iorqhich rhislcrmil is isn'cd My*orkc6 cor
<br />-lccnlfrrhor
<br />ii rhc p. orun olrhcworlf{n$hrhis prrnrir i\ i\\ucd.l shru n(r cnDkryinylrr{r ir 3nynlm cr
<br />$ nsro bc.oinc subi.t torh.workcrs coflrpcn\{riotr ol'Cnliior.ia. lodlsrccrhnr irl sh,uld h.co E subiti rolhc
<br />workcK com!.nsation ,mvisions ofSccriotr 1700 ot rhc L!h, Aiql \hall. ronh*irh comply wi'h rhor povkions
<br />WARNIN(: Irinnc n) \.curu qo'kdi $nrlrn! ii,, (,18. ( utrl.wtul. and shrll subFcl !n cmplorrr b.rininrl Ftrtrhics rnd
<br />in 0ddirior ro thc cosr o, compcnslrn,n. dritugcs .s Providcd li,r lhc.ivil fitrcs ut ro o.c hundrcd rhous.nd doll$s (SI(X
<br />S.crit 1016or rfu l.rlitr(til. tr .r.! rtr(1,
<br />,{, ?/t/lR
<br />DECLAEdIION
<br />Iheshyrinnunderpcnaltyofpcrjuryrhd1,,liccn{rlundcrpfl,vi\i{'nofCh,l)rcr9l.onnr*ncin[*irhSccri T(X)O) !fDivaidr:]
<br />of rh- Bu\ilcs d PmlcssionsCodc. trtrd ry liccn{ is ir Inllhrcc nndcrlirr
<br />'rc'tq
<br />7tt/t8 lLc<o,- P..,(r{ ir)
<br />CANSIBICIITNIIiNIIIICIIiEICI
<br />I turcby arfin! undcr Iicnah,ofpcrjuryrhr hcrc is r onnrudion r:ndm8 aecncy ior thc pcrforroncc ofrhe worr for which thir Frnril h
<br />h\ud (S(. lO9'7. Civ C ).
<br />AIETAtrfDLCI.Af,dUqN
<br />I trr.by Jl''m undcr Fnahy of pcrjory onc ol l[c rblbwnrS d{laral ions
<br />Oc'R,liii{,n Pcrn,it A+.sr.s Norificrrion Fcd.rrl RcEulario.slTillc40, Pan6)
<br />Rc!uir.d trnfi of Norifi .drion
<br />orlimrc$ rnd Sror. tr'ws Ehri lohtrild n!..n(n'.ri,r rnd hc,.h) trur
<br />*.vc nrihotrcd prot dt f0
<br />,\t)plirHnl or,\sml Six rlu
<br />h.ri<.prcsc divcs ollhis Cily lnd Colnry!o cnrd u,'on rhc
<br />-*,", a/ttlt\
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathing
<br />Shear Wall /-\
<br />Framing 7-11- !g \ \{-a)
<br />lnsu lation/Enerqy
<br />Drywall
<br />Ext.i lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />A\
<br />FINAL tuls-tx v,Y+\ev
<br />Certificate of Occupancy \J
<br />Notes, Remarks, Etc.
<br />Forms/Steel/Holdowns
<br />Lc .a.Nmc
<br />-
<br />-lcenifythor
<br />thc fcdcm I rcgu lar ions rcE dins asbcsros,cmvd uc nor arplicnblc ro this pmjKr.
<br />-l
<br />ccnify rhal I hslc read rfiis appli.ari'n srd il{c thdr rh. !h,!. intonMrion t cotral. lopre tocomFly wnh lllCryNnd County
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