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SITE-WORK DATE ID/SIG.COMMENTS
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Roof Shealhinq
<br />Shear Wall
<br />Framinq
<br />lnsulationi Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lr/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL loh1/lfr,.,D-?//.)
<br />Certificate ol Occu nc
<br />Notes, Remarks, Etc
<br />BUILDING. INSPECTOR RECORD
<br />OWNER Ot]II,DTJR DEI,CARATION
<br />I hdr.hy ll,lmr uftlcr p.nalry of pcrury rh.r I rm cxc.rnr ton rhc CoNrocknl l.t.tr* l-aw l;r rhc folloui'r8 rcrtoD lscc.7oll 5
<br />Iru\incss ind Proltsio! Co<lc): Aoy Ciry o! Counrt shich rcqlncs r lirmir r) ..tr(rucr, rller. imnnvc. cmoli\l' "r (trn rr,y
<br />dflcrtrrc. prior h ir\ isurncc. d$ rcqu k( rl.ij ,tDhant hr \u.h p.nnil tu li h ! si!rcrl nllcmni ih! h. or shc is li.cnscd |uNrrnr
<br />ro rfu pmli\nns ol rl[ Cotrlrrckr\ Liccnsd Lnw (Chrplcr 9. C.nnrdnc'n! wnh sc.ri.n 7ur) oI Divnion.l ofihc Bu\inrs\ nd
<br />E.r.ssnNCodc)orrhrthc.r\hchcic'npllhcrofronridlhcba\i\lorrhcrlLs.dcxcnrlion.Atryvi.llrionolSccri,nT0ll5hyrny
<br />nmliu furnnnir\ubj..hrhcrfpli.rntx'.civilpc.altyofnormorcrhlnfivchunmddollarslS5(D)
<br />-1.
<br />r\ o*ncr ol rhc rnFny. o, nry emlloyc.s *irh srac{ r\ rhcn k,h ..trFnsaliol s itl do lhc $ort aod rh. {n.'m s nor
<br />inrcndcd or oircr.d atr {lc (SLi 7Lr,l4, au$r.$ dPi(nt$n,nsColc:lhcContricktr\l-[cnscI:w.l..snorarf]yro0no*ncr.l
<br />rhc |nop.ny wth btri]ds or im|ni,vcs rh..Ntr. ud who dcs surh work hi'n\cll o' h.*clfor rhn,ugh his or hc! owrcmnbrces.
<br />lhlidcd rhrr iu.h i'npn*rmtrh urr rbr nlcnd.d d otldsl nr sok ll lr*.rr. rh. $oildi',! or impnrcnr i\ $ld wirhir or. )car
<br />of $ {brion- thc O*rcr BuiLir w,ll hak rtr burdin or ptuvir! rhd hr or {r dil En tlili or in{mw rh. pnlP.n, nr rhe Pu4${ ol
<br />I.nsownciorrhcpn,pcdy.,'ncxclusivcly.onlr.clirswilhliccnrd.onlra.t,Fk,coo{dcrrlEfrojc.l(S.t 7o14.liu trcs
<br />ufrl lhrfL\sirn Codc:'fhc Conrrsdoar Li.cnrc t-rw do.s nor lpply ro trn oencr.lnropcny who builds or ihprots rhcrcon.
<br />r.d who c.ddcctu such rrr.jNls wnh a 6.rBcro(, licctr*d pururnr b rh. conkdoas Lic.ns ljsl
<br />I rm cxcnrll undcr Scclio'L _. a & PC ttrrhis r&$i
<br />]rcf,KTBS:gDTlINSAIqN
<br />IIECI.ASAIPN
<br />I hcr.h, dmnnundcr lcmllyofFrjuryonc ol'thc lnlbwins dcclaruln,r:
<br />-lhrvcond
<br />willnuinraina C.nillcrr.olCon*trrro sctf ln\urc fir wor kcrf .. nD.nsnr ion. rs pmlidcd ror hl sccri{,n 1700 ofrhc
<br />Lahrc(dc, r{tr rhc trfonuNc olthcvork tuwhich rhc Fnnil ir issucd
<br />l0l hrL. i0d qill trhir ri| $ork.r\ .rtrr|[n.rri,D i'rurn.o. r. 'aqri'ltl by Sc.lion 3?mof rhc tibor Code. for rhc p.rroiluncc of
<br />ne cmicr at policy numbcr N:rl'. r.rl f.r *h'cr rhr ncnn jri$Lcl M) q^'rc'' J,{nFn.ri. n i' \d'J
<br />,"",", d).J"-/*.r',
<br />r 4?fis?Lrpir!\6-t4,
<br />-l
<br />ccdifyrhrrrn rhc !.rl'orDnccolrhc *ork In shichrhi\ pcrnn is i\nkd.I sl[ll n.r cn+kry rry ,{notr in rtry rnK_r
<br />$ a\ b h.coft srhJc.r r. rh. sorkc( conpcNmnr ldwr ol C.lifoi i!. rtri !Er.c rhrr if , sh.uld tE.onr subi.ct ro rh.
<br />workci\' rohltrnsrrii)n ptuvisio s ol sccl ior .17(D ol thc hhrr ( odc- I sMll. r,xrhsirh .o llny with rhosc P.ovniotrs.
<br />WAINING I'rilur. lo s.urc $orkcri conr|{nslli,'n cov.n'gc i\ utrlawrnl, d shrll nrhJccr M ctrDlorr h crinnrlFndri\ ntrd
<br />.ivil ircsupt,on [utrdrcn lhouslnd dolla^ ($100,(XX)r. in addirnnr n) rhc co( .i conlrnsarion. drnugc\ ]\ Pn,vid.d lnr rh.
<br />,,,", 1-ZC-rY "----2-
<br />IJIj;NU'DTOIIIBA(IIS
<br />J]I'(L,I8AII!.rI
<br />I hcrchy rffinnundcr Fn.ltyofFrjurylhil I ! liena!udcrpmlisionorCh,rrd9Grnnrrcin8sirhScclion7({r))orDivi\n:r
<br />oi rhc Blsincs rnd Profesn,n{4d.. md nry li(cnsc is in irllturc! cflirt
<br />L-( <.'
<br />14:,\-
<br />(o av s67
<br />th4L
<br />IANUB!,]SUqXTE!IUNIj.AIiEN!}
<br />I hcchy lifinn undcr pcnrhyot p.rjory rhdr rhcrc is a..n{fl.rn,n [ndir8 r3ctrcy for rh. Flrfonun.c orrhc sotk lar whEh rhh Ntrnil h
<br />issued(sa l(r97- civ. c.).
<br />hndcr'sNamc:-
<br />A.IILICANLDEEIAIIU,I2Ii
<br />I lE lhy dlinnundcr pcnrlry utt)rrjury onc ofrhd nnt,wirE ilc.hnrn rs:
<br />Ocnnnin,n Pcnlils A\t8s'o\ Norificrn,n F.dcrnlRcgulnbon\ (Tirlc J0.I' n1l)
<br />rd\lL, rnr I .rr ,)1 Nof nrlitn,
<br />I..nrfyrhxrrlr fcdcml rcSuLlions rcBelinE asl'ci.s rc ov!larc norrpplicrblcu rhi(Pr..)ccr
<br />xh^.'rn,'.n.,1 r ndv i,tr i'r,nLrri.,n.unk,*\'....-,--....',
<br />\pprnont or asrnr \iamrum "fZ'l
<br />P.rni,.rrunriDrin,,: Ld-e LE'
<br />q/rdtt
<br />Set Backs
<br />Subf loor/VenVlnsulation
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