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BUILDING- INSPECTOR RECORD
<br />DATE COMMENTS OWNER AUILDER DELCARATION
<br />I l[rchy dtlrr und.r Fnally ()l,xrjury rhd I an cxcm rom rh. G)nki.t)n Licns ljw li,r rhc ltu,,win! rca&r ls.c.?011.5
<br />Eurnc$ aRl Proltsion Orlc): ny Ciry or Counry qhrh rcquircs r lEm ro d,nntucr, .x.r, ,mPovc. dcnnnh or rnu .ny
<br />dndu... t iffb i's L*urkc. Jso rcqutcs lh. alplic{nl tursu.h If,mir t, tilc ! n*ncd sl.tcmnr rlur hco. sh. is lic.hs.d N(u,nt
<br />l,r lhe pn,vnionr ol rlE Conracttr's l-r.nsd Lf,w (Chrflcr e. C.mmcE_ins g'irh Sc.to. 7filo .r Divsion -1 oI lh. Ilusincss md
<br />I'n,r.ssidN Codc) or rhar hcorlhc is crcnurl rhcrclr.m d thc h$n tuIhc a]L-s.dcr.lllptnnl Any v0hrionotst.lt,nr0.ll 5 by,ny
<br />rttlir.nr ior. pcma suhJccrsrhc rnph.anr k,,(rvilpcn,ltrolnor mr. rhM lrvc hun,lrc.l nolh( (5500)
<br />-1.
<br />as own.r ol rhc I)roJEny. or m! cnlloFcs *ilh wrgcs rs rh.r vrL .onl).n<d ion, wU Jo rhc *. arn rtEdturmr nor
<br />'dcndcd or ollcrcd li,r s.lc (Sa.r044, Btrsincs rJ Prulcs(,nr CoJc Thc Conrri.kx s L,iccn{ tlw d.cs ndr apply n' an owncr ot
<br />rhcpr)Fny wlni hulds or nDoEs rlEB)n. arn wtu 'l,E su.h w()rk hinrcU or,irclfor rhrn'3h hi\ or h.i owh cnI'byccs.
<br />povdql rhar such impro!.mnh ft nor inrcndcJ rolta&{ lars.h ll, ho*cvcr. rlr hiLlsE d ml.&vcmnr is $ll $nhin onc y.r
<br />ol ory)k1ion. llE Owncr 6u0cr *ill luvc rhc hurJcn of 8,viry rhd hc or sft dil mn l'diltl or im0n,ec rhc fn,Fdy for lhc Ir4Ds oi
<br />-l,,sownrofrh.!tur.ny,amcrclusivclycotrl!.clir8whli.enscJcont.cr,RLrq,Nl.r.llhc|n*01(Scc.704{,Bunmssrkl Pnr6sbnCGlc:'! hc Conrr&lq s l-ic.n\c l-aw do.\ ndr,tply io anowncr ol po!.ny who bxilds or m[ovcs thcr@n,
<br />r vno !-nrmcr\ tx such pn,Fuc wirha c\nrn.lo(s) liLcnscd punud nr rh.c('ntrcttr s Uccne tj*).
<br />I rm.\.mpr unJcr Sc.l
<br />WORKERS' COIIIPFNSATTON
<br />I lrrchy aftirm undcr lcnilly oi p"*o ,'* ,,r,t," r.,to*in"ffiffiU
<br />-I
<br />hrvc ril wiu m,nrain. Ccdia.arcofCon*nr 6 Scll-lniur.lor wo*ds- urmFnsorhn. as politcd for byScctM l?00 ollhc
<br />tihn Codc, tu rhc pcrrorjMe oi thc work rbr whth lhc pcmn is nluc'l
<br />y'**"
<br />", *r, *,.oa *.rkcr' conFnsd n,n inrxratu., as rcquird by scuhon J 7(xr ol rhc ubDr cs.lc, lor rhc I'€rlo'Muc ot
<br />ihc wort ior whi.h this pcmir is issuol. My wo.kcta onP.nsalioh insurM(c cuicr a{ Flicy numh.r m:
<br />Cy'?e.€ss {\\(-ar.l r F
<br />)J(,"JcollBz(.
<br />Y! ccniryrid in rh.Frlm'nrnc.orrhc work ntrwhlhihr pcrmii is is\uc,l.l \h lhurcmlloyanyt non inanynr.nncr
<br />n, dlo hcom srbrcd ro rh. wodcr onpcnsarion lawr olCdiinr.i.. lnl a!rcc llur il t sh'ulJ h.$ft subj.ct lo tlrc
<br />w.*crs comtEnsarotr lrovFnrns otScrrion]T0oofrhc bh, c(xk,I dDll. tlnh*irhcomply wirh rl${ Pn)vrons
<br />NARNINC: hrlnr. k) rctrrc wrrkc's..onrpcn\di( .o\.ft!. tr rtrltqtul shall {'6jc{r rn cn{loyc' t' ui'nnrl fnahts a
<br />civil incs u0 h onc hnndrcd thousand &,llm ($loo,lIxl). io lJd ion ,nllrtrsrri,n,. ,]l ugc\ rs Frvklcd tu rhc
<br />Sr.r(r r(l?6ol rhcl-rhn (.ic. mlcrc{rrlr(ormy \n'c\
<br />ZO
<br />I herhyalrrdunJcr!'.nrllyotncdury rhlrI rnr li.cn{J unJrr l}n'vMr ol ChrPts 0 (connEkins wirhScrl n 70&) ol Divisi,,n l
<br />ol rhc Brsiocr\mJ Pftr.sson\CGlc. drl my liccnsc n tullli)Ezr cltd
<br />2- L-'|
<br />I 7
<br />gOIEIf,UCIION.LENUINGIIiINEI
<br />I hccby lllir nnJcr lEn.lly o{ Frjur} rhd rhcr! ilac,n{tucrirn hndn-! aeefry li'r rh. o.rfomm(c olrh. work forwhnhrhis pcmn t
<br />'ssucJ
<br />(Ser 1097, Crv C ).
<br />APPLICANT DF(]LARATION
<br />I trnhy {llim undc, p.nalry ol p.rjory onc of rh. follo*,nt Jc.lutl nnN
<br />DcnDhn,n Pcrmils-Alhcsros NotilicarRr F.dorl R.8ul{hrr (Trle 4ll, Fan6)
<br />Rcqtrt.d lxlcr oi Mnitierbn
<br />_l c.di,y rhar th. t.dcrd rcEubrbns rcsardins asbcsros rcm)val de nor ,$ncftb lo lhi poi{r.
<br />lal."niryri,* r U"".o,l rt,iiamlical,onrnd arclh rhc nh)vc inturmarion is comcr, I agrc. ro.otrrply wilh all Ciry ,nd Cdunry
<br />nrJoxnc.\ o'l Srarc l-rs\ (Ltn* l,r huiliJinrL.tr{.ron. el hrcby rrh(tr,c rlt..c rrvc( oi rhN Ciry ,nd Counry t cnrd rli n rh.
<br />rlx)vc rNnriorci ItnrNn! Itr tr!\Fcro.
<br /> Dpli.anl or AIcnl SiEnalum
<br />?4.J.,+^l
<br />I t3
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVlnsulation
<br />Rool Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsulationi Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certil.
<br />FINAL -zl-?2n y-w1i,l4 /-Llal ru 74r a,/
<br />Certilicate ol Occupancy At lZ-Zi-11 FrrL,!*
<br />Notes Remarks EtC.0 wr{
<br />(AL/
<br />SITE-WORK ID/SIG.
<br />lt)u
<br />tJn,ln'. NJn'
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