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BUILDING. INSPECTOR BECOHD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNEf, BUII-D[N DT'LC RATION
<br />I hcr.b, il5nn undcr r{n0lly of pcrjury lhot I m cxe.rfl 6om lhc G,nt ckm Li.cnsc tjw for rhc follo{in8 Ea$n (s.c ?0:ll 5
<br />Busincss nnd Prolcssion Codc) An, Cn, or Courrt shich requte\ r ,.i'nil ro (,xlflcl. ahcr. i'nloq dcmolirh 'tr rFn .
<br />'y
<br />srrucrurc. Dmr to ir\ ir\uaN- als ,cqlies rhc aptlicair fd \u.h ,rrnft b filc ! siSmd strtcmnr rhal lf, ur sh. n li.ctrfd pusua
<br />k, rhc pbvnn,nr or rhc Co.ra.rois Licctrscd L.w (ChaBcr 9, C.nmcncins wirh s..rion Tuxr of Dilision .1 of rhe Busincss and
<br />Pn tssiotrsCodc)orth,r hc or shc is cxcnu lhcrcno andlhcbtsihtrhcrllcs.dcrcnDlion.Atryviol0lionoiScc(ion?0ll5by,y
<br />.Ipli..nrfornFrnirsubj(l\rnclprrlicanrt,acililtculryornor sr h,n rivc hundrcd dollars(l5m)
<br />l. ,\ owdcr .r rhc tln)lxny. or my cnplo)ccs eirh woscs as rhen sE co ,p$\rr ioi. will do llr work xl thc slruclorc i\ Nn
<br />inrnd..d or odcrcd for sle ( Sa.?o14. Busin.s and Prolissions Cnlc Th. C.nrr..tois Liens Law docs aor rprly
<br />'o
<br />atr oqrcr ol
<br />rhc F,ncny *ho blilds or i,npmrl rhc(,n. "Ji *fio des sHh wo hiNsclf.rhcrslforrhmuehhi\orhcrowncnd.)ccs
<br />providcd th,r su.h i'mroknrnh !rc nol irlcded or orlercd rhr slc ll h,w.vcr, rh. buiUin8 or iq'roEnr n vnd wirhii otr. }.tu
<br />of .orytti.n. rhc O*rcr Duildcr *ill haE rhc t{rden or pmvins rhar lt or shc did ml build or inrmrc rhc loFny fo, lh. Fuqn* oi
<br />-l.aso*mrolthcpnl}cny.rmcrclu\nrlyconkarri,Uwiihhccn\.dconnNu\ri.otrnrudrh.P'{]J..r(Sc.7(!,1.aun.cs\afll t\Dfs\irn Codc: Thd CoitMr's Li.c trsc Lru docs n rr|Jrlyl('mo*trr.fPtuPnywhohtrrldsotirnPto!.!rhcrcotr.
<br />rrd who .otrtrcr\i,rs'.h l,mtc.h wirh rC.ikr.ro(n li.cnrcd punur n)llrContmktr\ t.i.c sc t-rw)
<br />I 'n,rr!'trnr dnJU sr.rr r .8(PC1,1 'F'c:.{'
<br />Dat.: ()knerl
<br />lvoRxFRs,c()tlPlNsa'noN
<br />l2EcbaarllN
<br />I hcrehy aiim rnd€r pendryorp.rruryuk orrhc Lllowin8 dcclaroriurr
<br />I hrlr dsill uini i'rrCcnlll..rcolCo scnt lo Scll-lrstc lor {orkc( o'npct\rrdt..s providcdlorbySccrnn,:l7l[)olrl{'
<br />laborCixlc.forrtupcrrornun..ofrhcworkfnrwhichrhclcnnir hisucd
<br />I lrvc rtrd NillnDflrir workcrr conDcnsilior iraurrmc. rr rcquircd hySr.riir:t7{D'', thc lrh.rCodc- ntrr}t |frf.' rn.c ol
<br />mpcisdn,n iniuraR..rricr {xl plicy numt}cr uc:
<br />U{CO'1 L-,oOa\9 1c t
<br />I ccrrily lh.r in lh. p.rfo.mrcc oirhc uork for *hich rhis pcrdir i! isucd. I shrll tror c,nploy 5ny pc^on in d., nlmntr
<br />h asrottcom subjecr Iorhewo,kc* comp.n\arion hwsorCrliromi.. md (8Rlhir iilskiukl h..ont srbr.cr rorhc
<br />N.rlcrs conrpcnsin,npn,visions ofSdrion:lT0Oolrhc tnhl (hdc.ldrall- i)nh!irh c.'ntly wirh rho* frolisions
<br />W RNINC: IaillE lo sccur worrcn (nnp.ndnn covcnfc is unbwful. rnd shrll \ul,ic.r n[ c rnli]cr to mnnnll Pcnrlri:s {d
<br />.ivil litrc\ rp ro onc hutulrcd rhoxsrnd dolles lslUl-000,. in ldninin b Ihc coi of..nr.nstrion. darMges !r Proridcd fo rhc
<br />Sc.rin':1076 orrh Lhr G c tr crcndnLlaxoru! s lcc'
<br />,.,"' "z/-lila"\ & n,,,,"".,, i<.&.e,U He.".o&r
<br />DECIIIAITON
<br />I hcrcby rllirn undcr pcoall, ofprrjrrr rhi I i'n li$n*l und* fbvi<ion or CMflc. 'r (comnrncin8 wnh s..rn,n TuxJ) ofl)ivision 3
<br />of lh. Bnsincss.trd PrntsionsCode. rnd myliccns. is i', tullfd.r rlcllcr
<br />R ft 2-?5A
<br />,",", : ?@9qe{ lsr $rv<-.tqri"<
<br />CONSIAIJCIION.LEIDING.{GIN1;I
<br />I hercb, arfiu undcr !.naltyolFduryrhd 'hac
<br />is ocoNlrudion L ingaEcn.y ror rhc p.irdimnoc ollhc*ork ntr*hi(hrhi\ r.rmir i\
<br />il{'.n (s( 10e7, clv c r
<br />AIIUCANfDIII.A&UIAN
<br />I lm{y rllim undcr ,cn!]ry oI p.rrury orc ol rhc li,ll,,*in8 d$hrari(nf
<br />l)cnplirion Pernrirs Ash.nor Noofr ion Fcdcr.l RcEuhiion\11it,c,10- Prn6r
<br />Roquncd IrIcr ol Noriri.ril(rl
<br />I.r'r,l,vrhd I hrlc rcld ihn iml
<br />o,ii'Bi.r\ and Srrrc Lrss mlnlirA nr
<br />{trrr nrnrionci fol.ny lnr iNl,.cr
<br />n ud shrc Ihnrrhc trtnle innnndi.n ir.orh-r. I rE € lo comtly wnh all Cny and ('ounry
<br />tr. m,l icrchy r rhori,r rrfrcsctr[tvcs ollhnCilymdCo"trryk,c r.r utotrrhc
<br />ADplir nl or.\8ul Si,: nhr.t
<br />CJ E4f@4
<br />rprla:is
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<br />ln s u Iation/E neroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL 6-z,l+a (L€t9 il€/tD3 '' 2 7
<br />Certif icate of Occupancy
<br />Notes, Remarks, Etc
<br />--+
<br />Erection Pads
<br />Flood Zone Certil.
<br />\
<br />l
<br />'.1.1
<br />. A'l l'r..
<br />- l.. lylhrr rhc r.,h'rlrcsrlxr(nrr rc8r'(Li')gn\hi,rr( x)vilr r n,{ xt)Jrl .rhl. n, rln\t)(rr.r
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