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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BI]ILOER DELCARATION
<br />I h.rcby aljim uftlcr lrmlly i)l Frrury lhar I u crcmni lioar rh. Conrrrcn,6' l-icn\c liw nr rhc iiil,,*ine rcrn'n (S( 70.11 |
<br />Bunnc$ ,nd Prutas\ion Cirl.): An, Ciry or CDUtrry wh,ch rcqurc\ a pcm t) .onnnrr. .llcr, ,mpRrvc. dcmol$h or qrftny
<br />dru.rulc. pi{tr r' ils ts..nuc. ako rcquircs rhe amlic{d tu su.h Fm r. tilc a srnc'l daremnr lhar hc or shc i\ licc!{d pu. ant
<br />ro rhc prvisknrs ot Ih. Contrlctor's Lf,cnsd L.* (Chdt'r( 9, Commkinf * h Selbn T(xxJ ol Diri\ion .l olrhc Ansircss rnd
<br />Pnrf.soff Culc) or rhd h. or:hc ir crcmpr rhnclrom rn'l rh. basi\ tor rhc rllqcJ.r.,halion Any vn,hhonolSerionl0ll.5 hy rny
<br />applrc, tutrr.mnrsrhjc.h thc qlllrant loa.iv,lp..axyol nornurrhrn tivc hundrcJ dollatr (5500)
<br />l1-\.r!run.'ufrh.Irindr.o'm,cn'nr,,Jcc!wrh*Jee.Irhcu\,l., ntn. i,'n.uillJ',rh.riiAnl'h.{tu,mi.nnr
<br />i, cnLd or oflircd for $lc (Scd.?(x4, aurincss md Ptuf.$ions Cdl. Thc Co.tacktr-s Liccnsc ljw dG. nol !!dy lo u owncr ol
<br />rhc F,rf,n, wtx' hu d\or i,q,,,ks rhcN)n,,nl wh,&f,ssuchunt himsclr orhcrscllorrhruurhhi\o!hcrowntnlnloyccs.
<br />,rcvklcd lhdr su.h ifrpDkmn* m tu! inrctulcJ or of,trc]] ,6r $k ll lx*.Er, rh. huium8 or ihln,rmni tr sru wi6in nnc )rr
<br />of.o!ryhlot. rh. Own$ BurLr will hrE thc hunknofnruvin8 rhrrhcorshcJrl rcr hu l or unl,rulc r l,uFny for rhc tl{rlxM nl
<br />-1,
<br />as.*Nr olllE pn,Frly. !m qclusivciy .onlr&rina villr liccnsc! conlncloN lo mnsrd.r rlE pojcclise. r0.t4, Blsincs
<br />Md Pnlfasiln Codc: Thc Conkicktr r l-(.ns. Lrw dkr nor ,pply b rn own.r ol ttun fly wh(, hu ilds or mprDv.( Ih.r.on,
<br />lnd sno otrl@ls iitr su.h pmtccls w h o Ctnhclorls) lirc.s.n pu6u. n, rhc Cotrlr.ckn s Lnen* L.w).
<br />-I
<br />anctcmpr trndcr Scctnl ll & l,C tur thr rcr*)n.
<br />t*-z'ry'""", l- 7- 2aizs .-^,,XJA-.,,s f€DPffiDEII IAUSN
<br />I hcrchyrll NunJ.r |].Mk!ol Frltrry .nc ol rhc l(nLia ! ,ic.hr. nn\:
<br />I hrlc lil wiu nDonar i Ccnntrrc of Con*nr ro Sclitnnrd nr wdrkcrf onrt'.nurirr rs t'n,vilcd tu hy Seton l70O ol lhc
<br />khtr Cc{c, Lrrhc P,rtamuc. ofrh. wor* fd whkh rhc p.m trLr{d.
<br />I havc and vill nrainhm workcrr q'mp.nsarb, rtrsurrEc. !s lcqurcd hy Sc.l i,)n l70O oI rhc l-lho! O,Jc, ttr rhc Frrnmec oi
<br />rhc work,nr vhich lhis o€mil is niucd. My *orkcN .ompctrs0tn,n insurun c.rier a.n Flicy numt . uc:
<br />Pohy Nunb.r Ernias:
<br />I.cnily rhir in rhc lcr,nrrone of rhc work tor whal rhr Fcm,t is issucd. I drll nor cmfloy any pcron in rny mmncr
<br />e' 6 to bed,E uhjcd h rh. krrkcn @mr.nsalbn llws ol Cslinrmia, anl 4rec lhar iI I should hccome subjccl k' lhc
<br />M,rtcs comrcnsarn,n provisn,ns oi Scdbn 1700 of rhe hhr Grlc, I shall. thnh* nh con y wirh ihoE pmlhions
<br />WARNIN(;: Frilurc h Elrc M)rkcri comp.nsarn,n $wasc ir unhwtul. ud sluu subjer an cnrlloycr lo dinDrl lleMlrFs a,
<br />civil tin.! up ro one hunJE{ lh.us ,l d{,llan (Sloo.mo), in a&l(r}n l. rhc.osr of$mFnsrlion. damscs as Brvided for rhc
<br />50ri,n l0l4ulrhc hll{ C,nc. d.r^J dtl,nt,m} \ r.c.l-l . zn z-
<br />DECL{RATION
<br />I lEEby ltltrnundcr F..llyorp.rjury ttut I n Lc.nsol undcr pNvlrion.l Chrplcr 9 (coflmrinS wilh Sation rUJo) ol DivGion l
<br />ol thc Busin.s e Pbfc*ir.s Codc. Mt ny lrcnsc 6 in full fimc all .ftacr.
<br />Liene Cla$r_Licenic Nomh..
<br />Conl*tor.-
<br />c0xirBu!:lroN.ltll)tx(iiclNcv
<br />I h.rhy lirnund.r p.nrlry ot Flurytharth.6 r r.oi{ructron LnJma d8.my ntr rhc !.dnnnrtuc ofrh. work ior wh(h rhir IEmd (
<br />nsuell (Scc 10r7. Crv. C.)
<br />l
<br />AIIIIC NLrEcl A{MN
<br />I Lfttry.rlim r.'ld Fnrlryofp.rjlry onc otrh. nnkrwmS Jclrari,ns:
<br />D.nr,lnon Pcr.nB Ash.no\ Notlicari(,n F.Jcrdl RcAuhro,r(-l lcr(). Pr16)
<br />_Rcqumd ktr&dl Notiiorion
<br />l.cnrlythlr rhc lclcnl rcrulatotrs r8ndin3 a$csros r.ft,vrl rrc n.t {t'h.$lc n, rhh pDjc.r
<br /><ll ccn,ry rhd I h,k rca'l rhi\ rppliurionrJ dricrh,r rh.rh,vc rn rmdn,n treor.cr.I r[rLrbc.mrly w hdlcryrndcounrt
<br />ordlrrk.l rnd Slarc ljws r.lnu4 ro huildi.! cohdtucrn'n. anl hcret y aurhorr. rl,c\cir*v.\ ofrhr C y$d Cdudlyrocnrd ulm rh.
<br />ahrv. nrnrk'ncJFrpcny tnr i
<br />Anplicsnl or AFenl SiENlure t-r-2,80
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf looriVenVlnsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Brown Coat
<br />Masonry
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil.
<br />FINAL 1l*o t lt;'- l 2<,)knntrt-&X-1
<br />Certificate of Occu pancy
<br />NeteF, Flemarks, Etc.
<br />{-d
<br />c -b I
<br />I o a-o'wlr-
<br />20.-5 -lt
<br />Forms/Steel/Holdowns
<br />Ext./lnt. Lath
<br />Pool Fence
<br />I
<br />tl II
<br />t
<br />Drt :_
<br />I{ftlcr'. A,lJrc$
<br />p.nrn@na "en ,,\-'-'t f tfi--+ €'t>/12F4a.?'
<br />tt
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