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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE IDiSIG.OWNER BUII-DEI' DELCARA ION
<br />I hcrchy ,lton und( Fndlly of lf, lury tld I m cxcnfl lDm rhc Ci'ntrlcl,E Li.cnsc La* n, rhc nnbwin8 r.Nnt (SN.70] l t
<br />Busincs a Prufcsi(,n Cdc): An, Ciry., O,unry ,hEh reqnircs r Irfr, t' c.n{rud. akcr. rmpov.. &nnlnh or Eprn !,y
<br />(rucrur. pturr' ns sruancc, aL$ rcqun s lhc d,rplrrnr tursuch ltnnf !' lik r nEtrc naEmnl thlr heor shc t li{nscd perruanr
<br />ro rhc F,rnn,ns oI rh. Conrrxcrois l-ic.nscJ ljw (Ch.flcr 9. Conm.nrins wirh s(ton 1000 or Divtion i of lltr Busircss atrd
<br />Pof*noni Cod.) or rhdr h. or sh. 6 .rcq)r rh.rcftun Dd rlr brsi! 1,tr rhc rllcecd c(mplotr. Any virhln,n ol Sccrn n 70.1 I 5 hy rny
<br />appli.s nn ! pcrmil subJcch lhc 0mlicanl k, !civilp.nalryolnor frtrcrhr! lrvc htrnJrcJ Jolles l$5tx)).
<br />)
<br />I. is o*ncr.frhc l)r)JEny. or my cmlLyes w(h vaecs $ rh.t hlc @mpcn.ibn. wiu Jo rbc *$1,,*l rhc ituim { Nr
<br />inrcBrGr oroliiEi ror slc (Sa 7044. ArsD.s nnd Pmhsion\ C(xlc Thc C(,ntacktr'{ Lr.nsc Ijw docs nol atply ro.. owncrol
<br />lhe pn)Frly whD btr1iis or inDmvcs thca)n..Rl who docs \uch w(nl( himscllor hc,selior rhd,eh nn or hq oq.nrployccr,
<br />pR,lrlcJ rhrr suc[ impowmnB d nn inr.nJcJ oror]ircJ nn\ft ll.lxrqcv.'. rlrhdiu ,g or iqmwmnr is n'1, wirhi,r .rE ]cd
<br />o{ conlpLrirn. rh. OwNr Builq wil n"r $c hunlcn ol p viry rh2r hc o! sh. Jrl mr hi}] or itr{.orc rhr ttuFn, ldr lh. plrFE Dr
<br />_1. owncr o, rhc Fopcdy. drclu\ivclt co.rtucrint wirh lun*'t ont cro^ h co.{rucr rh. F)j.cr (Se 7t}14, Bn{rcs
<br />a Fn)lissioCodc: ThcConrncttr r Lircnsc l-{wloes mrapplyn, nnoeo.rorlln,lc y*ho hu,Ur.r if,tnvcs rhcrcon.
<br />and who .onrkts n, {ch pbjccB wxh , ci, rrcbn t lcnkd Furna ri rhc conr!{untri Lncns ljw).
<br />I.mcrcnry undcr Sc.rro. ,A &P.C.k rhkrer$r
<br />\VORKI]RS' COI\IPENSATION
<br />09e!4xl!ll0N
<br />I hc!.hy illtnrundcr IrndlryolpcrjrtryorEol rhc tull,)wtrU dcuhr onr
<br />_l tuv. aJrl eiU @inrzB a Ccd frarc of Ci,iur t, Sclf l n{rc n)r work F' .omFn\.r idr. ds !ft)vdcJ fi, by Sc.lion 1700 of rhc
<br />I iu Ciltc. lt, rhc pl-nnmuncc oa rh. wort tur whth rhc pcmn is r\ucd
<br />\-I hrvc d wnl mainr,ih work.r' coml,.ns ion nsura..., a! Fqun d bySeriotr l?(x) olrh. LlborCo.le,16r rte lltrfoodc. dr
<br />lh. srk for whrh lli\ Fmir a i!sk{. My worl.B Unn nsarion insumc ffkr !x, fi)lty .umbc, re:
<br />.'*,",, . 5 l.l.t '?- "-.\
<br />I 20 l\{--l'z
<br />l ccnriy rhlr in rlrc pcri.nlancc oldrc work $! shich rhF Frm tr issucJ,l \hdl nor cnfk,y rny p.Ron r My n'Mtrcr
<br />$ a\t'trc.m srhFLr h rhc wo*c^ .onlEh\rrioh hw\ofcrl,ftxu dJ d$,e rhd il I dDuld hcrrrc srh].d n'llE
<br />workc^' Ll,hp.nsrlon tR,vr\stu of S&rbn 1700 of rhc lihor Cqlc. I \h l, Ld hwirh cdnrply wrth lhoc pn,visr)ns
<br />WARNING lirlrc r, r.urc w(trkcn uomIlcn\rri{,,..vcB8c is unhwlnl. anJ \hall suhj.cr ,t cnrpnJycr k' smiMl lEtr.llrs i d
<br />civll ri'rcs tf r) onc hun,lrcJ rhou\mJ ,lolhn (s1 (o! ol .o ]|risrrnni. drnitlcr .,r t,'ovihn ltr rlr
<br />19'?c',
<br />!.2rll -8!rrlr
<br />I hcE6y alitm u crl)cnilryol pcrjuryrhlr I am h(nkl un'lcrpn)visi{,n.fChrprcr9(.ohnEmx,! w hSc(ton?0001ol Olvnnrn l
<br />ol tu Brsncss ind Prrtsons()Jc. u'.1nry |ccn{ is in lull lnr{ l.l'li.r
<br />1b 5 7 1 C 3
<br />D0'.: -- l-15 Zct
<br />CONSTRUCTION I ENDING A(;ENCY
<br />I heEhy aitirDuftlcr pcnalryolpcrjury rh lhe.c n aqrnslruclion lenlins lsem, nrr
<br />'tu Irrforlmc. or rh. work ti,r whiuh lhs pcmit ir
<br />hsrcd (S€c 10t7, Civ. C.).
<br />AITLICANLIECIABATAN
<br />I lh$y rllidr rn'l.r p.nalry ofp.rjryom ot rh. n,Uowin[ Jccldardns:
<br />Dcmohrn,n Pcrmih-Aih.dos Norilicariun Fc'l.ral Re8ularioni (Tirlc 40, Pd6)
<br />_RcquiEd L.uo o, Norff,arion
<br />LI (.dirr rhd I tuh rc i rht,pr)ic rton ril nrrcrh rlr rhovc n,lornhtotr 11(!nc(r I arre to.omply wirh allCiry rn,l Counry
<br />rivcs oi th{ Ciy and Counrrro cnrcr rpon rh.okl,nrn..\ in,l s(rrc l_as\ tuhnry L,nl hc'chy.trrhorzc rq,r.scnr.
<br />rlx)r. rh-nrr c! Dn)pcny 1,tr m --2------t--ls- 2 <::
<br />Appli.{ orAEcntSiEtr{l
<br />P.-u
<br />Set Backs
<br />Forms/Sleel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation /1.
<br />Roof Sheathinq z/r/"t -Mrn
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext.i lnt. Lath
<br />Brown Coat
<br />[/lasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil.
<br />I
<br />FINAL 4ra/i) .**h/ l
<br />Certif icale of Occupancy /
<br />Notes, Remarks, Etc.
<br />COMMENTS
<br />tr.r.
<br />t n'lcrs Addrcs
<br />I (cnrlyrh rhc li t.rrl rcgrhri,,trr r.ernlir! a\bcdo\ !cNNrl rr. nor atnl'.rhlc n, rhn tojcrr
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