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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNIlR BUILDER DELCAI'ATION
<br />I hcrcby rl'i.nr undcr pcndlry {)f Pcrlury lhrr Ia cxunu lmn rh. C.ntrro.s l.iccns ltrw lar rlk tillowira rcri (S..70115
<br />Bu\inc\\ xl Pn)ltssion C dc): Any Ciry or Counry whi.h rcquircs a Pcnlir b oi{rucr. alra, inPn'Yc dcnFlhh or rcPan uy
<br />{tu rur.. |nt,b ns issu0ncc- aho r.quirc\ rhc,trdtnnl lor suci Pcrnir lo lilc n siSncd sikmnt rhd lf,or shc is lic.n{J Ilrhxdnr
<br />l(, lhc ,!o!ision\ of rhd C.trrnrlols l-iccnEd lnw (Chaltcr I connncncilr8 wilh S..rirn 7(xx) of Divnion.l ofrhl Btr(in's rnd
<br />Pnric\\i{,nsCodc)or lh.t hcor shc iscxcmprrh.rcfro itrd lhcbusis li'r lhc tlltlcd cxcnwirr Atry!iohrn,nofSdir)n?0:ll5by!try
<br />npfli.rtrrror.lcrmirsu$jcckrh.amli.d.troa.ivilNnoltyol.ornnmrhirivchundrcddollarsl$5{x))
<br />-1.
<br />.$ncrorlhcDoNny.,rnrycarPl.)tts*irhs0.!csasthcnhhconrPc \dnnr. silld. rlrc $ork rtrd rhc nMlurc is ry
<br />idckl*l orolltrcd nr eh lS-_ 7041.Itnsinc$$d holtsii'nr Codcr ThcCortrncntr \ L-ir.n\c Law do$ lor amly t, . osn$ol
<br />rhcpn)pcny wh. hurlds or nnpmrE rkr.!n. rxl stf,) &f,\ such sti( [nn\clfor ltrull.r rhrough hG or hlr osn cnr!nrv..s.
<br />nrovilcd rhlr \uch inDddf,nB m,h, inrcndtd .r .llircl lorsk ll howc\t!. rll ttikiin! ot nnpmrtrm h$ld withinonc )tr
<br />orconDlcrion. rlr o$rcr Euildcr $illhrvc rlf, ho,tctr oi Piorine lhd ht or \ht dil tror build or inDr.vc lnc lmEnv for rh. Nilrsc oi
<br />-1.
<br />a{ ownc! oa rhc pmFny. .m cxclu(ivcly conkd ir! wirh li..n\cd (.nrltttr\ kt .onnrud rlf, ProFr (S.c ?O1'' B!$ncss
<br />,trd lh'li\sir (.odc: Thc ConlracrN s Liccnsc L.N dDcs nol aPrly ro sn.wncr oit'.oPcn, wh{) bx,lds or i.nprcrc( rhcr.otr.
<br />. d who conhcrs ior such tlojc.8 silh r Conl,rcb(\) licchscd nusuanllo lhc Conta.rols Licen* Lrs)
<br />s
<br />DECIA.BAIION
<br />, hcr.by atfirr utulcr Fn,h, olperjuryonc orih. rdlowir8 dcclrdion\,
<br />-lnrvc"trdsillm0i
<br />.inaCcnilEdeorco.sctrrlosclf-lnsurchrsorkcn.onrpcns nrn-ast$vidcdlorblSccrnrnlTfl|orrhc
<br />Llhx Code. nn rh. FrromDncc oflhc work f., which rhi pLYnil h isucd.
<br />I ha\r .nd will mnintlin workcrs .ump.nsrrio. insu.arcc. as t quircd by Sar io. :l,m of rh. tjbor ( odc. tor rhu Pc.fonurcc ot
<br />$c work lir *nicfi rhhI].nnn ir issd. Myworksl cotnpensrrn,n nr\urincccaricr aid policv numhc, rc
<br />l'('licvNumh.i
<br />Iccnifyrhrrnrrhc$rliflutr.rolrhcworkto!shichrhi!Pc!trirhi\sucd.IshrllnolcnDloyrtry!.nninrnyntntrcr
<br />e, dsI.bcoN suhJc€r x,rhcso*cn comPcnslli,)n hs\orcarird ir. n rEruc rhd irI shonld bc.oN subir.t turlE
<br />rukcr{ cotrIDn{d ion pii'visi.ns ol sccr i()n ll00 oi rhc litrtr cdlc, ! shrl,. hnhsirh .omflt sirh rho{ F)vnnn'\.
<br />$AftNINGT ljlilurc t, s.trrc workcri .onrpcnsrri{,n corcngc il otrlawtuL rdd sh.ll suhjccl m cnrpkJvcr ro oiDinnl lri!lr'\ trd
<br />(ivil lincs ut t, onc hun rcd rhousnnd dolln( l$l(x),(xD). irr
<br />-_2_A/?-
<br />compcn\nnrl dinugcs !s povid.d Lr rhc
<br />S..ri,in:1076 ofrhd lrb.r ('.dc, inrcrcn
<br />Dr'.: g:- / t-/ /
<br />DECI,AIAUqN
<br />I hcrchy !|fi,d lndcr Fn.ht ol p.rjury rhar l,d li.x.sd undcr Imvisi{,n orchnPl.r 9 (commtuing with SNlbo 7ff)0) "Divti'n
<br />l
<br />ut rhc Busimss md Prfc*ioos codc. n ny liccnsc is in rull lorc. orncfitcr
<br />Li\cn\c Nunb.r
<br />--CoNSTRt]Cl'ION LFNDIN(; A(;EN(IY
<br />I hc{hy afiir trtrdc!IEnallyotp.rjuryrhdrhcrcn!con{.ri lcndir8 rgcncy fu rlf, l).rformncc of rhc sork for shich rhi\ lj.rnrir k
<br />is\!ed (Scc .1097, Civ. C.)
<br />APPI ICAN'T I'F(]I ARA'I'ION
<br />I lrml,, alrmr r.dcr rnllry or pcrjrrt oN of rhc l'ollo{in8 dslmri(,'\
<br />Dcn,llrio. Pcnnirs Asbcsros N.rificrrbn FL{crnl R.AulrrirnN lTirlr40. Pad()
<br />_Rcqrncd krrcr oi Notifi crri{,n
<br />I ccnilyih'r rhc fcJml rc8ulations rcSeling srh.ios rcn$ulorc nor nfitli.lblc ro rhn In.)ccl
<br />-lcdityihd
<br />I hrvcrcidlhhaDplic rn,i xlslarclh rhclbovci.tunn $r iscotrccr IrENroconDlvoirhallCilvondCounrv
<br />H:t[" :;:: ffi'%#:l Z& :.:"':;A;; "
<br />p,mi,enome(pr,n,): fi A'lllttt o Pt /V/a n,t
<br />Set Backs
<br />Forms/Steel/Holdowns )
<br />Erection Pads -JgUFER Ground 7) /,U
<br />SLAB Floor / z/o't/t{ -t,w^ul)
<br />Subf loor/VenVlnsu lation l"l
<br />Roof Sheathinq
<br />,//a/zq '/&l7-l t
<br />Framinq tt tv
<br />lnsulation/Enerq v / / /-'r47
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />[/]asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certil.
<br />FINAL /d -ll ',ri v,\i.i-z;
<br />Certificate of Occupancy t
<br />Notes, Remarks, Elc
<br />\7
<br />.JX?,^
<br />ilwe\
<br />Shear Wall
<br />\.,-,
<br />r\
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