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BUILDING- INSPECTOR RECOHD
<br />SITE-WORK DATE ID/SIG.()llNlili Bt ,tI.:R t)t:t,( ,\R,\ 0N
<br />I hcrcby ifllrN undcr Fmrry r)r n rJUry rhf I a r crcnpr ri.m rhc Conkrt,6 Lkctrs t r tur thc lollotr ins rca\on rscc 1r-1 1 5
<br />Bulincss ud Proltsion Codc): Any Cil! or County whi.h rdquircr a l]cnhir lo coNru.r. alr$, impkrc, d.nrli\h or rcFrr zny
<br />{tu.1urc. prtnio irs ns!a"cc- ako rcqtrircs rh. aprlica lnr such Frtrrit h liha si8trcd $arcrmnr lhd lEor shc t liccnscd rufiu.flt
<br />h rhc novnions ol lhc Cotrrrcktr \ Li.crs.d bw (ch,prcr 9- Conrmkins wnh sccrion 7fi)o ot Division :l orrhc Bu\ilds rnJ
<br />Profcssion\ Codc) orrh.l hcorshc iscic,npl rhcrcliomrid rhc b t r(rrh. lcE.dcr'nprion Anyvidrrn'.olsc.ri.i70ll5hyrn,
<br />aptlicrnr f(tr (Fnnil suhj.clsrhc aprlicntrr to r.ivil0cnrlryofnornor.rhm llv. hxndicd dolhr($500)
<br />-l-
<br />rs ownctofrhc Pmpcn y. fi ny.nrdoyei {irh wr!c\asrhcn q'k conwtrssrion, *illdo rhc s.rk drhc{dcr@isBn
<br />inrcndcd or oilcred for elc ( Ss.7(,44. ltusinc$ Md Prcfc$iotr\ Cadc rhc Cotrtrr.lol s Li.cnr tiw docr ml 4,rly ro rn o{ cr .r
<br />rhcrmrEdy who boilda.r irtn)vc\ rh.6n, and wtF d6 q.h wnli hinselfor hcrcllor lhrnusn hn or hcr.str emlloycei.
<br />Pn,vidcd rhrr su.h nn|,orcnrnts !E mt i.rcndcd n o!l.$d for suh ll. hosc\ri rh. hoildin8 or infn,vctunr i\ qnd within on yt
<br />ol conulclioa. ltE Ostrd Builds rrllh.vc rhchurdciofrruli'rgrh,r hcor\h.d aor hiklorimporc thc pmldy firrhcpuqxMol
<br />I.r\owncrotlhclroNny.rtrrqcluri\cllcont&rinSqirhli.ctr\.d..nka.ntr\ro.o{ruc[hctyo]c.r(S..70,14.Bunnc\\
<br />rI ftJlalli codc Th.(in rrcror\ l-i..n\c I nr (locs tror rltlyr0 rnowncr nlfr.pcny{ho t'uilds or iqrrovc\ rhcrcon.
<br />rnJ $ho.onrrr.r\f{rn(htrotc.rrsnhaConh.nflrlnarncdnurnmrk)rhcCofurktrsl-i.c{l-xwr
<br />I rnrxcnrnr un,lcr Scclion_
<br />D8r. _ , oencr
<br />woRIFns, coitPEr\tsal roN
<br />PECIdIA.IIO!
<br />I hcrcby amrm undcr p.nntry of Frjury.rc nflhc rolloeins dcclamrions:
<br />-lhrtrndsillnuinlaitr!CcnifiqlcofConscnrt,S.lr.lnsurcrorsorl(cK.rnpcnelbn.asl,n'vid.dr(trbyS.cliotrl70oolth.Llh)r Codc. lor lh. pdrorn1me ol th. !o* for whi.h tlk pcmir is iss&d
<br />Ihavcandwillmai ,in work.ra..dpcnslrion insurlrc. rs requncd by Sccrio.l70O oithc Liho. Codc, for rhc performncc of
<br />lhc wo* ror whkh rhia p.mii is nsu.d. My wortcB .omrctrsrion nNururcc caEicr and l[lt, numhcr s.
<br />Policy Nnnbcr:_
<br />-l.cniiyrhrr
<br />irrhcNrlor rnrccofrlr.$.rkn, trlrichrhnp.i,nir i\ i\\u.J I \lull nor cnDn)y rnv pc'1otr i', riy nri .r
<br />n) t,aL 'x $hlc.t b th. *orkci\'.on,pcnsrrio.lnw\ of(alnnnra. rnd rlNcrhirifl shouklhc.om nrhjccr rortE
<br />w,k&i conrFisrrn,npRririor\orsccrn lT(x)olrhcl.llhtrC.d. I \hrll. ni[$irIc.n ys]rhrhoscr.vnioir
<br />\llRNlN(; Inilurc k, $.r. sork.^ .onrfr \rri($ ro\drxgc i\ unhstu. rftl\hrll htcci m c'nnl,r)cr k' fti'ni'RLn nalri.s rnJ
<br />civil lincs qr ro onc hu.dEd rlrusond d.llas ($l0O,0U)), in nddnbn ru rhc.od .ftrlltrl\rrxrn dr rc\ r\ frnd.d nn rhr:*y-i;ily /-)
<br />I hcrcby am n und.r Il.nalrr .r Icrjrry rhll I an lienst undcr !,ornn,n ol Chaprcr 9 (rmmrcin8 with SNlion 70O r) of Uivhion 3
<br />.f rhc Dusincssrnd PmfcsionsCodc, a,rd mr lrcnsc is in tulltur& md.fli{i I@reg)NIIA.USDQNIINO,INGdiENCI
<br />I hcrcby aflinn und$ Ji.nakyoftf,rjurvrhar rhdc nacon(rucli.n h inslSctrcy for rhc lcrfonuncc of rllt *ork lor\hichrhtI)C nr n
<br />issu.d{s* 1097_civ c )tr df r NMrc: _
<br />AIELIIANfIIECI,AAAIIAN
<br />I hcrc$y aJlinn u nd.r !.mxy or p.rjury on. or rh. rollowins dcclnrarions:
<br />Dcnbliri.n P..nirs A\hcdosNorili.ariorFcdcrrl Rc8ull(ionr(Tillc40. Pan6r
<br />Rcquncd trtcrol Norili.nr oi
<br />-l
<br />erlilirhd rnc icdcral rcEulnrions rc8.rdnr8 r\tE{o(Jr r,v.lrrc ior imli.*|.n' rhis nnrf.r
<br />l(niry'hnr I lx,vc rcad lhis{pplicrrion Md shlelll.l rhc il\,vc ir nrr([ trr'tr'c.r Insrcr r,.,tr]rr)h \nh rll( iry n il(rr ty
<br />ordi' ncc\ rnJ Srrc LrBs rchring ro huillirE con(nr.ri.n.oulhorir rcrr.k aliv.s of
<br />Jln\d rmnrioncd prcn nytar i
<br />Appll.hnl.. Agenl Signn(uE
<br />b e-r k
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Shear Wall
<br />Framing
<br />lnsulation/Ene rgy
<br />D all
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It/ason ry
<br />Pool Fence
<br />Handica Re
<br />De puty Final Report
<br />Engineer Final Report
<br />FINAL q/u//,{,\Gg
<br />Certificate of Occupancy
<br />Notes Remarks, Etc.
<br />COMMENTS
<br />Forms/Steel/Holdowns
<br />Rool Sheathinq
<br />T-Bar
<br />Flood Zone Certil.
<br />lxndcis Ad ns:
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