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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.owNrR lt(:lLtrlk I)lll-( lRAl l(rN
<br />I hcrcby rifirm under pcnahy (,f Frjury lhll I m c(cnrnr ,h)n rhc Conk{.lo6 l.idn* Lrw for rhc touowing tavr (So ?0:ll 5
<br />Blsincs anJ P(nas\t,n Codc): Atry C y or counry Rhi.h rclurcr r pcdnr h .on{rucr, allcr. innovc. d.nrlNh or Epat ov
<br />{ru.rm. prbr b ns nsusncc. a\o rcqur.s th. .t'dicol lnr such Frhn k, l,lc a sisne,j nlrc'tnr rhd hc o, shc t li.cn{,] pu(u,nt
<br />b rh. ln,vsn r ol ltE Conka.ttr\ l-ic.nscd ti* (ch,Icr I, Comnrh.'in8 wirh Selrln 7dx) o, Diltion 1 or rhc aulin.ss ,nd
<br />Pnrcsnons Conc)orrhlr ncorsh. s.rcnpr lhcrcfron a.d lhc hasir ntr rhcrllcgcJcrenrprn,n nyvnrlahonofsari)n70115 hyrny
<br />attlic. tu!pcmirsubj.c6ihc,mli.anlh,.i!nFnaxyolnotmrrclhan,ivchundr.dJours(5500)
<br />I. ,( owrcr ol lhc Dn'pcn y, or nry cfrnloyc$ q( h v.8cs as rhcu n,lc .ohP.ns{ rn. *ill.lo rh. wdl xnd rhc nndw t n
<br />ircnl!.,1 or ollbr,i tur \dlc (Se 7044. Busincs and Pnna* nr CL{.: lhcConrra(r'\ I-i.cflr tiw Jocs nor apllv hdowE ol
<br />rhc pn,F-dy wl$ hilds or itrllbEr rh.B& uxl *lx' Jrs \kh k,* h'mscll ot hcr{ll or rhroush hn or hcr o*n cryrnrv.cs
<br />providcJ rhlr su(h mpruKmn( d nor rtcfrkn or ofleErl li{ ek lf, h,mvcr, rh. hurura or itrlPRrwntnr N oll within ^nc rr
<br />oi uomphrn r. rhc Owncr Bn Jc! will hnk rlr hrd.n ol pbvin! lhd h. or rhc JiJ nor hu l or iml'orc rhc Ir!,FJty f.t rh. Puq$c ol
<br />L ds owncr ol rlrc pnpcdy. rn .xclunvcly uontncr iry *rrh l(cns.J conk{tor lo !.n(rucr rhc 8,jccr (Se. 1s4, B {ncs
<br />and l,Idalsin CoJ.: Tlr Cotrtr.(I,tr s l-iccn\. Lrw docs norqrPly n) an o$nc..l F)pcay wll) builJs or innn)v.s lhcrc.n.
<br />.nJ who uonrrruk ri, uch l)n)iets wilh ! ContE(b( 9 liccn{'t pur{hm tu llE Conkrcd's Ltctre liw)
<br />I rmc\cnrpr ttrJ.r Sccri.
<br />WORKERS' COITPENSAITON
<br />DECLARATION
<br />I hcEby arim xnd.i p.nahy ol pcriury orc orrhc roltowinB deltllions:
<br />-I
<br />hrv. ,il will minlain a Ccniiclrc .f Conscnt to Sclf-ltNurc lbr ktrk R' onlJlcns.tiofl. as pmviJ.d tirr hv Sc.lion l7(xl da rh.
<br />tihr CoJ€, tor rhc p.rrom ot rlE *ork tor whih rhc pcmn s rsucd.
<br />I hrv. .trd will nuinrrr workcN .ontEtrrilDn in\uu... r\ tuqutr d hy Sc.ri,D .l7(X) ol rlr Uh., CoJc, ltr rhc pcrlonnMcc .t
<br />rhc w.!klnrlhi.hths F-.r.ir L( rsuo.l. My workr\' .ohr.nsrr 'on nui.trcc.amcr anl pl'cy nulrbcr de:
<br />Policy Nunber:-4 4 o
<br />-l
<br />ccnity rhnt rn rhc pcrlhrm&c.l rh.workfor whkh llns t'cnnil is 6{r'1,I \hrll n.r cnfloy,oyF*on inrnvmnnrcr
<br />s !s h bc$m uhFd tr rh. wDrk .omFtrsalion hw\ ol Crhl,nni! an,, 4B rhar ia I \htuld b..om subi.tr b ilE
<br />workcrs conpcnra( i{i n ttu vs io,r\ ol Scchon -l?(D ol U.ljhtrCrxi..l dull. bnhwirh cohtly wt h n,sPovhnrns.
<br />WARNING: Fdlurc t] sculworlcn (,mf.nsrt n covcr.Sc is unh*iol, dJ shdll suhj..r an chlkry.r k, diniral Pcn.lris a*l
<br />(r,L lnr\ uf i, otr. htrtrrll.n r[nu\rn] J,iLlxr( rSll i. rJJrrkrn k, rhc (od of.onrPcnsarnn,. Jrmlcs
<br />Scct n 1076.1rlr LrhtrCulc. mrcrcd mJ d,-i-Ppl
<br />ltrtt!!Bdr!1]-\
<br />I hcrcby ,t1trn uftld p.nalty of Frjury thal I am licnqtrl und.r Pn-hion ol Chaprs 9 (.ommncins wnh S&tbn ,000) o, Divtio. l
<br />ol rhc Brsin s! and Ptufcssions Codc, dtl my li.cnsc 6 in tull lilre ori cllccr'
<br />,-,**"*/**,o q
<br />1-t2-l'1 1
<br />CONSTRUCTION LENDING GI'NCY
<br />I hcrchy rinm u*lcr pcmlry ol txriury rhir rhcrc t r c.nnrucrr)tr bnJirs,3.fty lrtr rlt Fdnrnrah-c ol rhc *.rk ror ehich rllh Frnrir il
<br />isnr.,l (Scc ll)97. Crv C )
<br />trnJri\ A,lJrc$:
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<br />ATTLICANT DECLARATION
<br />I lx!$'y liim utulcr penrlryott'criury one oarhc n,Uowins,lccl,rxron(:
<br />Dcnrliron Pcrmir$Ass.nos Nonli$trcn licdcral Rcsrlnhon! (Tirlc 40, Pan6)
<br />R.qutcJ lrn.' of Nolil.rrknr
<br />I c.nilidrlr rhe L'l(il rc8uhtn,ns rc3{,lin8 asb.rt,i rcni)v.t {c mr alpl'.rtL ro rhs p^lccr
<br />-l
<br />.c ,ry rh{ I hrrc rc.l rhh qDli.arion aJrl natc rh.l lrHh,vc infomurion is .orut. I a3re b coolly with rll Citv aal Counrv
<br />ordimnr.\ dSrxrc Lawsrchlhg h prcscnt{rircs ol rhis Ciry 3il C.utrry n) cnt.r upt)n lh.
<br />Applictrnt or ,|Cnl Si(..1o n-1212i
<br />ildinN .on(ru.ridr. and hcEt'y aultxtrr.
<br />to
<br />TI
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Roof Sheathino I ?72 DkM ot .4n
<br />Shear Wall rl
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lvlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certif
<br />I I
<br />FINAL t N D* n)t nFtT
<br />lr
<br />Notes, Remarks, Etc.
<br />COMMENTS
<br />Erection Pads
<br />Subf loor/VenVl nsulation
<br />ft.v. nErronc'l lr'j^.dy lar
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