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BUILDING. INSPECTOR RECORD
<br />SITE.WORK ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenUlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Fram inq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />t\
<br />FINAL
<br />Certificate of Occupancy lr I
<br />Notes, Remarks, Etc
<br />OWNER BUII.DER DI]I-(.ARATION
<br />Ih6.q(.mrmufllspolhyofrqjur,-lhdIe.(mFfrohrlECodrrcloFlrGl!\forlh.aollo\ri4r.Mn(S<70rl5
<br />BuiirB! !,!l Pkrldion Cct) a.y Cirv or cou t trhich r.q!t6 r Ft'l ro odrud, th6, imF.r( danolEh { rgEn r'
<br />rturfu4 F" b ,b Bum.. .60 Eq!n6 lh. .prlrcul ror rNh Frhn h fik . igEj rd.lMr thi rE or sh. is lic6!.d poFrr
<br />h rh. ,m\6irB or llt (irtsroi. Li.6!.d t!$ {Ct4{q I, Comrn8 $dh s<iirn ?()0() of DritFtr ! ol rh. truind .nd
<br />Pmldhnr (-od.) nr rld lr G nE i d@F llEtfrch !d rlE bd6 for tlE .lk*.d ddnnn Atrt \ iobrion.l Sdrso Torl 5 i^ ,n)
<br />ar'pllcr t r . Fmn $bFdr rrt q,pli(mr ro a.i!il F tr orml mrclho n\c huDd,.d {0116Ilr0O}
<br />L s o$ffi of rh. FiFny. or m, cmph!6 unh trt86 d ih.n $k.onrtturn. u &ll!*<*Ird rrnrrEiml
<br />iddd.d rofiF€d foreL{SETOr{, BsiB dd PrbadroB ( o& lhc (tnrrlor'! lI.B tiw rloG nol Tply lo d d\6 oa
<br />tlEFFry * lh hnlr. d irr..i€ tlEb( dd sh. &E sh H'* h,m.lr or h*lf or lhmus.h nir ot hq oM dPlo)6.
<br />provid.d lnn sucn imFlEFrl e dr indriat oroltad for sb rr, hotr6s. rh. tr d4 or nqlltlrd ir $ld *irhin ok )a
<br />of.ompLl iotr rlE ()$16 Alilb *iI nav. lt'. hr,a of FowE rh, lE or rlE dii d hild or inpror! th. FoFry fot iE FrF k ol
<br />l. 6osnd orlhc Forcly. dn .rcluriv.ly .onr.dint sirh llc6.<l (ffaclo,! h q,drud rh. pmjNr 156. 7ol'l- l]l$nal
<br />and hrliisim(irl. lh.(onr.ct t l,ic.nse Lawdo6 not flppryt, ino*n6olnNFnyBho buildso' impirnsiho.on.
<br />ind uho $nlmdsnn luch rmjtns *irh a ( ommckr(s) lrm*d p!r$!!l ro I h. ( tnftdoiq I i..a tas)
<br />I dn.\.nlfl u.tjs s<hon ,a &P( Lrlhnr.&n
<br />D.re Oi.d
<br />raaf,EBt:(a ttdrarlu
<br />DICIjAATI}!
<br />I h6.t') afli,rn undd po'hr oIFJun oNofrlk follor inr &.ld!rnnt
<br />Ih&.al$rll
<br />'nr!m
<br />. ( diaEll. otcolsar 16 s.lf lnEC n, {.rt* c.mFldion. s I'.riH fo. b S<l$n 1nn oa rhr
<br />Lrbr (ix!. ld ih. p6fffi. otrhc N* for rtth lhc Fn'l . Bru.n
<br />I h.\. anrl Nll m.,nr n $0116' (mFlsatio. iMBNr, 6 rcqur.d b tidnl 17m of rh. Iit Cod.. for lh. Ff.l1M.. ol
<br />lh. *orl for *hEhrhsr,dnil s sdt M' \rort6'comrrEdion r6u,sc.crF tdFl'.) nunb.r dc
<br />lcolifyrhar inrh.trL,mh..of lh.$ork for*hichlhs pcrm'r is 'ss'.d,I shill n.i cnploy sny Pc6on in tnt mannd
<br />e s l. b..om. srhjd! t' lh. tr ork6l comFnerion la*i dl ( tl'Lmi., dnd qrE rhd ,r I lhould lt(of,. subjat lo tl'.
<br />$ ort6' connd$! n$ t,.\ Bn)$ or S.cftn 1700 ol rh. L.b.r ( G1.. I shll. fon htr il h $tply {nh rkJe pm\ isioN
<br />$ RNIN(; Ij,'lur. t, ru. $ork6 comFMior co\@s. ir unlNrul- md .h.ll rubjGl u @pLyr to (tif,i..l F..ii6 4,J
<br />cn ,l nnd u, to oE hundr.l rhouend dollm (5100.0i1)). in ldd n'n n) rh. coi of comFNt trr d,n.$6 !s Inor d.d a( (h.
<br />s{h.n m76 .l rh. Llnr c.& nr6d .nd dotu ! rc
<br />I ha*y tlIm uida Frxy of Frrt rhd I m licsE d ur& Ftrvinn 6f (lu9rd 9 l@mnjftin8 r hn sdrn nm) of I)i\ i3tn !
<br />of rlE BuiB .d Pmt6i!6 Co&. .i fty liaE i! h tull 6N !d .fid
<br />,". l(1
<br />/I 7
<br />tr!'cd(s.. 1l)i)r.(tr ( )
<br />APPLICANT DECLAAATl(IN
<br />I hd*y lIfF !idc. rE.hy ot Fju, r. oE of dE foll.$ ir8 dclm' p.3
<br />t>mlnm !mi!-A!tBro! Nor'ficnon Pcd.nl R.iohl bB lT{!. .10, Id6)
<br />R.qut.d ldr6.f NxrtdM
<br />I .dify rhd !h. f.nf,l EtuLtioB r.sErIrs 6h61.. r@vtl e. mr tprltlbk ro lht Foi.tl
<br />I cdifyrh! I h.!r ranl lhi lppli6lio. ad nn. rh.r rh.6lr{. infomrio. i! coE.l l!s'dro.om0ry"nhtllC'ly3.d('ounrt
<br />oidin.n.6 dnd Srd. llrs rcll(',{ ro hlilding 6tr sri hdq( iolhni/. r.l,6dlaxv6 o I rhis ( ny d Counr) r,' or( urr.n rh.
<br />at rr 'ndrFn.n ptuld, tu iNp.clior It1A|,|,li.{nr.r A*dl Si*tr{lfl i(.e<J-t,- qu<-Ll,--"^r,, I , I L
<br />lzl1tt\rtrElll
<br />DATE
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