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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OIVNER BUILT'ER DELCARATION
<br />I hcrcbt alhlm un'lcr pcnahy ol p.riury rh.r I am erchtr fr.n rhc ConirrrB LEnsc Llw nrr rhe li)lbwmF eNrn (Src.ru]l 5
<br />Uusircss rnJ I'rolcsrm Co.lc): Any Ciry or o)unly which rcqun \ I lFmr lo rondo.r' ,lter. impnvc. &nt Lsh I rcnrir uy
<br />inktrtrc, pnor f. irs issunc.,,lso rcqntrcslhc lPpncanr ra' {,rhltnnilto lilc a s+h.dsrdcnEnr lhai h.dr shc is liuen*d lNdr
<br />i,) lhe povisi{}n\ oi ir. Conrr&nn s Li.cn\cJ L,w (CnaPlcr 9. Comnoncr8 wiih Scurirn 7l(x} dr Diltnm I of rh' Btrsin's rnd
<br />Prulision\ Codc) or rhnt hc or sh. tr cx. rt'l rhcrcliom nBl rhc hass f(tr lhc lcScJ ei.n,lrion AnvviohrninotS.crion ?O:115 hran,
<br />.ptluDr tnr ! p.mrir l,jccrs thc .!,,1i.!nr lo d cilil lcnrhyornor norc tMn tivc hn drcd,l.ll s ($5(xl)
<br />-1,
<br />owncrotthcpopeny.ornycmtl'ryeswnh*+csasrhctr*rc.onrncnsarion will do lhc *orl 8l rlr eruiurc is nor
<br />d.nhn or olfcFl br sl. rSL! 7044. Brsinc$ rnd Pnncsons CoJq lhc Gft..ntr s Litcn\c lf,q d.c( nol amlv h d dwnq ol
<br />rhc Ix)IEdy qho hlrlds or itr{x,B rhoBtrt. lnd rhr Jr\ flch k)tl{ hunscll or hcEcll or rhnnr3h ht o, hcr own cntPlovcc\,
<br />,r,vdc'l rhar{kh i'npn'lcnf, nB ar nor L .nJcJ nr.llc8l hn \rk lrl hot!.r rhc huill!ry o. inll)nvcmnr s $l'l *irhin on. t{t
<br />.l conll'bti)n. rhc owtur Bnild.r will hi'r rrE hrJ.n ot t)n)vm8 lhlr h. or sh3 Jd ft bu d or inrlln*r rhc m)rcnv t6r rtE PurI.* of
<br />t. rs.wncro, rhc pflrp.ny, amex.lusivclyconticlDg w h lrcnscJ conta(,N to con(ru.rrh. nn)j.cr (Sc..7044. Bu\in'(
<br />!,xl l\rft*r,n C dc l hc ftnk crn's Ltctrsc t,iv Jocs nor r0Ply t) rtr owncr ot 0r,I)cny who huilds or inpruvcs rhcrcon,
<br />.nJ who L.nrd.r\ for su.h InrFrk wih a Contrctnc) lsctrrJ p.runnrhllf,(onka.!tr's L(ns tjw)
<br />I rmc1.n,f tr dcr Sc.rtr,
<br />ItllS6ElSlCOUtrNSArIO!p[clrl8allo!
<br />I h..chy antrn ntulcr lcn.lly .l Frjury ox or rhc ttllo*ine dNlffarion{l
<br />I hsvcad willmri ai, ! Ccrrific,rc .r Conrcnl ro Sclllnstrr. li'r wotkc( .om!.nsaton. ns psvdcd ntr hv Scdi l?{ ol'hc
<br />Irbltr a\jc, n)r rhc p.rfo.nMcc ol lhc wolt for whih rh. P.mil is n\!cJ
<br />=-h^.
<br />inJ w,ll mr mla m r,{kc^' ( umFnd !,n m\urrnLc, ai dqutcJ hy Scrrion .r70o of lhc tihor Codc, ror thc lcrlomc' or
<br />thc hrk i qhici lhis Fd,ir ii sucJ My work.G' conFniario, i.suancc cEkr and IDIEv rumhcr a.l
<br />11-o r<-].c, \-1 ,k(L.vaL
<br />-l
<br />rcnili rhxr
<br />'n
<br />lhc pcrlarmrNcolrhc w.rk irtr wh'.h(his Pcrnr is r\suc(|,I shrl! or crnkrv lnv Peno. rn itry manncr
<br />\o xs r) bc(nN s,'hFrr h ih. Brtr*.r' conP.lsrron law\ ofcalrbflu. inJ Js(c rh{ lf I sl'.uld hcc.m \uhicd llt rh.
<br />soRcH .onrFnr i,,n nn)v$ions.l Scclon.]700olrhc l-rl{r (iic,l $rll. ,,nhq(h omplv wirhrlkxc f()visDns.
<br />WARNIN(;: Fdlnn ro \ccurc *orkcs'conF*nrilnD .o\rogc ,s unliwtul, Md slEll luhrcr lrr cmolo}lr k) 6mhrlPcmlris and
<br />civrl I'nc\ un L'.rc hn rc'l rhou\nJ J ll.n {il([),rxx)). r a'ld(nn ro rhc.o{ ot .onlrnsrrirrr. Jrnuscs rs an]vi'lcJ ltr rhe
<br />Sc.!nr,r076 rlthc l-rtxtr(oJc, i' crc{ JtrJ dll({trcy s iiet
<br />uElL 8ul!]!
<br />I l[Eby arltm un,lcr l.nrlryoipcrjuy rhar I m l'.cnal nnJcr pNvision ofChrprcr 9 (.ommncinr wtrh Scction,ml) 'rr''vi(i'n 1
<br />or rh. Busincssanl Pn,,c$ ns colc, i my licen\c tr ntullrorccu calccr
<br />\C)2qb
<br />rlorl-?-cr
<br />|llNs't'Rll{'Ttr)N l-ENDIN(; ac!lNc\
<br />I h.rhy allrmunds pcnsllrolNrjuryihal rnm t a con\rBcrion Ltuli,Is rscn(y n* rhc pcriormanuc ol rhc qo* br wfiich rhii Frmit is
<br />rslcn (Scc.]097, Civ. c.)
<br />APPLICANT T}E(]LARATION
<br />I trrchy xlim utulcr pcnally olt rjury onc of lhc lbllowin3 'lccl,nlons:
<br />DeRn(n,n P.rmiN^sh.(.s Norilicsrnrn Fcd.rdl Rquhlions frnL,rc, Pd6)
<br />_R.quihd txtrcr ol Nori,idrir
<br />l(rDr9rlt' rlr li,fin '.et
<br />!f.d rv,lL I h.r.ru,r,h'rf
<br />onl'mnQs itrJ Srxk' ljs j lcuring
<br />rhhons rcsdi.rr\b.{o\tc ovrlarc nor rtlllr$h lo lhilpn,icrr
<br />1,liedon ialc rhrr rhc rlx,v. nli,rmalnr ir ron.er' l.Ercc ro.onr0ly wdhnll Crrv an(lCounr,
<br />n) huddn! e.nnru.r(n rftl hrrchynur r.lr.\.nturnc\(nthtr(iryr J(i rtrrlhctrr.rtrT rlr
<br />ihov. nrnr(in.'l la,|f,ny n* fftf,.r
<br />Appli.xnl or ,\genl Stnalure t q C)
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/Vent/l nsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsu latio n/Ene rqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certif
<br />4IF|NAL i /L'// o-AA)/.-Ld/Ua (
<br />Certilicate ol Occupancy
<br />Notes, Remarks, Etc
<br />r,,,r,, r*,r,-, Q € \4-2o '-\ 1 F e-. -Z- r"n-.,
<br />r.r-*.cr"*, ( .^ \s I.r.n\cNtri$.r
<br />l-cnJcrs A'lJrc\\:
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