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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNI.)R BTIII,DI:R I),CARATION
<br />I h.r.by ,fnr undd p.ndry of p.rIry th.r I m .x.trpr fdn rlr. Contero6 tr..s. t w for rtE follo{iru Ea$, rS...?031.5
<br />Burin.s Md Pro{c*ri.n C.d.) Any Chy or Cornry uhich rcquncr . ,.mir $ c.n{rucr. alrs. i'npsve. d.ml or Epgn xny
<br />,oc.u... pir ro irs issuar.. als. EqurEs rh. applic r ror $.h IEmi b 6lc o sgrd datr rhr tE or sb. il lic.ned pusdr
<br />t. rhc tofii.ns oI rh. Contacrolr l,iccnscd tiw (Chao.r 9, Commcncina wrh Scdi.n 7Ul0 orDivision I ollhe Busine$ a.d
<br />Pota$onsCod.)orrhdh.orsh.ir.x.hprrhcroIisdandrl*b6iJLrrh.ulh8.d.xcmprior. nyvill,i{nrofs@rion70ll.5bylny
<br />ipplicror for itEnnir rubl.cs rh. q,Dlic.trrro0civil!r.Mhyofnormr.rh lrvc hundrcd doll0r ($5Ur).
<br />_1, a oqn.r .l rh! nr.Itiy. .r my .mpkrltcs qirh w{.s $ rhcir ytc c.mtcn\ar i.n, w l d. rhc *rrr ,id (h. dmkft ! MI
<br />inkBl.it or ollr.d for sl. (Se 7044, Buriftsr and Ptuf.ssion. Co!. TIE Coau.crols l-i.ie Llw dcr ndl lPply ro m owrr or
<br />rh. pDp.ny who builds or in{,owx uErtr and wb docs su.h mlt hiosdll or hcrsll or rhhwh hir or hd own emplott.r,
<br />providcd rh sucb irymEmd\ m mr inrcrncd o.oltcod lor $L ll, hoscvd, ih. boildiry r n4rowmnr ir sld *nhin@ yta
<br />ol on{n.rbl rh. O*id BuikLr will hiv. rh. bunhn of povi'rs rltu lr or sh. JiJ nor boitl or irnpmv. ttE pFliaty tr rlE IDrFdc or
<br />L $ownciofrlE p$n.rly, rn.rlurvelr.ofurc(i,!3 wnh lilered conrrr(u\to.oNrrucr rh. poj-r tsd.'7044, Buii*s\
<br />lDl l\oLssl Ct d.: Th. Contlcror'\ Liccuse tis do6 mt al'plyb oo*n.r olproPtnr*bo builds or ihrrov.s rheran.
<br />Md wh. conrrcrs lor such poieN wirh a Conrmcro(s) licensed ptrhuad ro rlE Conmdorr Li(nsc bw)
<br />I rn.\.n' ( d.' Sccrnl
<br />!!]1ts[!8!_Cullr!l{ra!
<br />!.D!t4.BrL!.0N
<br />I h.rchr_ rinmund.r |anrlrvolpsju.vonc olrhr tul[Nin! ncclrtrt.i,i
<br />Ih!v.andwrllminroinsCtnilio.t.ofconenibS.l nsuE lor workns' $mp.rBiior, $ prcvid.J for b, S.crion 1700 of rtr
<br />l!6.r A c. tor rn p.rlo.@c orrh. wort tor $hth rrE Il(nn n i\sucd
<br />Z-h!v. lnd will rot !n! work.u c.n{rNotion inrunnc.. is equiE l by Sarion 37m of rh. trbor Cod.. for rh. P?.lo,lre! of
<br />nr sork for wlich rhh n€rmn h is$Erl. My ror*c omp.n$rnn rnsuldcc ceicr and ,rolicy numher trcl
<br />Ic.nrryrlur inrh. perfomrnnce al rlE *o.k lor whichrhis |{mrir is iisucd,l shnu nor .nrplo, m, l)cr$n ii any mdNt
<br />e as ro hc.o'E subj.d ro rhc wo*c^ conrpcns.lion laws.fCnlilo.n'., md l3dc rhtrr ifl should h.cor subjed btlE
<br />*o*eh lan!,ersatDD pDviliotr\ ofs.cuon l?l)Ooflh. L,bor CoJ.,l shrll, fonhwirhconplyw hrlDepovsions
<br />WARNINC: Flllur. Io scu. workcK' molEtrslrn,n covdr€c i! unLwtuL md nBll suhjcd e c.{loycr ro rinitil lEn ra ind
<br />.,vrl fitr.s ut r. onc hundr.d rhoui.trd dollar (sl0lr,{xxr, in addirio. h rh. cos of comp.$arion, drm8.r ,s provid.d fo. rh.
<br />----2
<br />t)t:(l-1t{,\TI()N
<br />I hcrcby arn'.undd p.nalry.tpcr trMcr 0r.v'sir)n ., Chipc 9 1..'n' n.in! qirhScdiof 7(x)()) .l Dirisi.n 3
<br />of rl'c Brsincss md Ptufestutu CeL, dl hy ltc.sc is m tull f(tre turl .flccr
<br />i.-* N/-r*,/o 3e3 7/
<br />z/e ,/z nar1/
<br />I h.Eby afirm und.r FMly ., FrJUry rhn i
<br />isstcd(Scc. 1097.Ci! C).
<br />r mrnrud i,, LtrJi,g ag.'ry tor ih. p.rtoroE of rh. rork lor rhi.h ttus ,.rnir is
<br />ArIU(ANI.DLCLASAIION
<br />I h.Eby llim ualer p.nalry ot p.rju.y onc o, lh. followios &sldarioos:
<br />Demlirion P.rnic'Ashclror Ndifi.dion F.d.rd R.Sul ioDs (T l..10, P.n6)
<br />R.{ur.d Llrer of l'1xi6"?rion
<br />-l!.nitirh
<br />rhe t'l.alregulliod r.gxln'B }h.sro\ Rnx,vdJr. 'kr nfplicrhl. t, rl' pnj.tr
<br />-f41d't) h.i rh/\e rdLr,h'\.'ppri ,ion ad nar. rharrh. ibov. inlom{rioi n uorur I a!@ ro Nndy wirn all Ciry and Cdunly
<br />iry .odo.riotr rrJ h.mby rurbrir. npr.enrdi!.s oflh]l Ciry brd C.utrry io .ord trpon tlE
<br />i lr^r trilnirdl t,r,tnlrr ,ttr
<br />11ppliclnl or gctrt Signnttrrt ., <zt ^
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />It4asonry
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certil.eaivz- frfil,...-r+-z/zry,/za /42t7
<br />FINAL ULA,/?)hCn Jezo> 2,
<br />Certificate of Occupancv
<br />Notes, Remarks, Etc.
<br />Rev. 08-07-2015
<br />Sublloor/VenVlnsulation
<br />Pool Fence
<br />n,,n*"*, /l 4zk-A)tbG&z- r,,oi,^,-s/n/zo
<br />S.dn,n 1076ofrlr tlhor Cidd, inr.ren and
<br />2/tq /, ^
<br />tt
<br />t
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