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BUILDING- INSPECTOR RECORD
<br />COMMENTSSITE-WORK DATE tD/stG.OWNER BUILDER DF:t,CARATION
<br />I hcehy alltn lndfi Fndly or pcrjury lhar I I crcmnr to rh. ci, t!clo$' Liucn{ ljw lor rh. tullowbs rc.s,tr (S'.rc 70l l 5
<br />Busincss anJ Prorc$ion Culc): Any Ciry or Counry whth rcquircs r lcrmir b con(rucr. rllcr. imrovc. &BrEh i rcp,tr dy '(rucrurc. Drin l,) irs issulnL{, at$ rcquircs lhc amli.anl tbr su(h I'cmir b lil. r s(xi rldcnrnt lhll h. or rhc i\ li.cnsd JNNa
<br />nl rh. pnv"ons of 0E Conlri.tx s LienscJ Lr* (chafl.r 9. commNins *nh Sern'. Tootl ol oivision I ol rh. Rtriir* .h,i
<br />Pda$nrns Codc) o, rh,r h. or rh. N.rchpl rhdclionanU rhc b3{s lbr rh. alkEQl crcmtri.n. Any vtrlationdrsccrion 7011.5 bv rnv
<br />amlicmt tur rpcmn subjei. lhe alpli.rnrb a.ivrFnrlryol nol nxxdhan fiY. hlndrcd doll ($50oJ.
<br />L as ortui olrh. phFny, ormycmtloyccs wirh w3!c\ a\ rhcn s)h conrFcnsalnln, wiln. rh. wdk ni rhc sterr tr tur
<br />inrcnd.d or oiarld nx sb (So.7044. BuriRsi and Pn*cssrns Cqlc: llE Conkucntri Li.cns l-.w dmi nor tt'Plv r).n owncr.f
<br />rhc pDlrd, wh) Iinills or iqn)Er r&m4 a,ri wl$ des ssh s.t* himrcllor hc6clfor rhnnfh ht or hcr oqn cmPlovccs
<br />Fn,vdcd rhlr su.h impokrBnk N mt i cdGl or oiixri $. s .. Il hwcvct, ttr huitlins or inlmrEmnt s $tl wirhin anc ycr
<br />ol compldi)n. rhc owncr Blilier wil h,w (h. hun]ch of nrcvin8 lh.r tE or shc ilil x, hu'tJ .t r{'()rc lhc I,oIEly f{tr rhc Puqhs or
<br />t. asowncroi rh. porrdy. rmciclusivcly.o.tacrins wirh lic.tr{J conra.lon i).on<oct rlE ln,r.tr (s.{. ?(,4, B{\inc$
<br />a l Pnnar\bncl)dcr'I hc Conlraukr's Liccnr. Lrwdo.( n.r{Plyn) anowncroflllop.iiywho builds r nnprovcs rh.rcon.
<br />and who uonr,rk lilr {ch pk'jeh wnh . Co.traclo( s) lncn*'l prrnrrnr I' rh. contaclr! l-itcn{ Ii*)
<br />Dnte:-
<br />lVOR(ERS' COI\IPENSATION
<br />DESldSArlON
<br />I hcrchy allirnr un,ls pcnxhyorpcrjury.rc.l rhc lbllt,winr !t.clt&ri(rtsl
<br />-lhrv.rnd*illnlai,ain{Ccnri.lreolConr.nrbS.[-r.turcli,rwo*cnNnlcnsdn'n,.rnruvidcdlbrbyScctsn]70OofrhcL{hrr C*lc. ritr rhc p.rtormkc of lhc work litr whi.h rhe p.mir i! slucJ.
<br />ill r'n,".'A *itt..in*. *"rkc$ co.rlE,rs.lion iNurfrc- ascqut d hy S&lrnr 'l7r)O otrhc Lrhor Cndc, ti)r lhc pcdnmtuc.r
<br />lhc mrkltr *hichrhtFmir is issucd. My workcr' comlcnsari,,n m\ur.n.c .Mrr {rl F)licy numhct d c:
<br />Slq /e- F "a,lq//\q-ao'2A
<br />-l
<br />ccnitrrhar r rhclcrl.rDn coIlhc work n, wh'chrlris ltrnn is ssucJ.l drll tur .n{'loy .ny J'cron in iny mdrcr
<br />$ ,sb hc.onE srbrcl lo rhc q,i(.h dnnp.n\nldn law! oicalin]mia. ud JsEc rl[l ill should h.srnE shid Io trE
<br />wolkc* omll.nslrtun !tuvisnrns olS.crion 1700ot thc ljhtr GiqI dBU. fonheirh co,nPl! wirh rl&$ Pmvist,h!
<br />WARNIN(; Failur ro *ruic *ork.rs .onpcnsarbn covcragc ir oihwtul, dn'i \lrJll suhFrt m.frt'loycr b .riminal IEMlt.. .nd
<br />ciril nn.\ up to on. hnnJrcti rhousrd JoUm ($lul,mo). in .!'iition b rhc con of.rnrcosar
<br />S..rn{ 10?6 ollhcljiinCGlc, inr.rc{ ind.lk}nEy s tccs.
<br />I hcruhv xllnm unl., Dcflillyoiperitry rhd I.m utrJd Il.vNi,r lChrflcr n rns wih S.criln 70m) oiDrvnn,n.r
<br />of thc arift$ n.d Pn,fcsnms O)dc, ,Jrt y I'c.nrc i\ m lull ttrr lol cilccr
<br />L . io/
<br />{utg .\" - a/l l
<br />C9NiIAICUOA!ENI)$C.AGENCI
<br />I hcFby attm un,i6 Fn,lry or pcrjury lhar thcrc k . .udodi'o r:ndre nScEy lor rhc netromncc of thc work ir which lhk 0crmn s
<br />iisuL{ {sa. 109?, civ. c.)
<br />,r Ji\ JJ|..\:
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<br />APPL!CANT DECLABATION
<br />I hcrcby afm un,icr Fnalry drFrtuty.nc o, rhc loll,)wing Jc.ldri,ns:
<br />D.ndirhn Pcrmih-Ashcnos Norif( 'od
<br />FcdcrrlRclublnlns ('I lc40, Pd6)
<br />RcqurcJ lr(dol Norincditrr
<br />I knify rhal lhe lcleral rcsulsrions hEddina lsb.nos r.fr)ral m nor rptlklbh lo this p(,Jc!l.
<br />UZI cdilyrhd I h,vc rca.l rhN lp,iliclliirn a {at rhxr $..hovc oLlmrion ir.orel I a8rc ro omdy virt rll ciry and Cou.lv
<br />onlinane! anJ Sr,t. kws rclarins lo $lildins 6.sttulio.. .nd ncrchy iuthotu. rr*ntariv.s oi this Cil y alrl Counry ro c.l€r uFrn lhc
<br />mlc mcnrurJ pnl.dl fd i,rspdlion
<br />^
<br />k t-.p0
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />SubllooriVent/l nsu lation
<br />Rool Sheathing I Dlrpo .*w
<br />Shear Wall
<br />Framino
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnl. Lath
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certil.
<br />FINAL 2312 ? N{Y)3--L +k9
<br />Certificate ot Occupancy
<br />Notes, Remarks, Etc.
<br />0 e //
<br />I t bkttaty'at Vz L tt
<br />-t
<br />Brown Coat
<br />B & PC fu' rhs rca!,n
<br />""," - /- K-ad
<br />t/ nJe'" Nrm:
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<br />-T
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