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BUILDING. INSPECTOR RECOFD
<br />SITE.WORK DATE COMMENTS OWNER 8T]It,DER DELCARATION
<br />I hcrclJy ariirn undcr pcnrlry oa trrjury ih,r Ln cxcml rnnn rh. Conkdon l.iccnsc liw fo. rhc lollosii! r.,$n ($c 70.11 5
<br />Burincs {d Pnlcsion (ndc) ny Cily or Coutrly trhiih rcquirc\ a Ilc nir ro condflcr. ,lr.r. imp('!c. dcrmli$ or rcI)a, my
<br />(ructurc. prhrto ils issu!rcc. oho rcqunes lhc fp]icnnr Lr suchFnnir lo filc a sicmd n,rr'ft.r rhd tuorrhc Ls li.enscd i'u^t!d
<br />ro rhc pi{,rhn,ns of rL Conkn.r{n \ l-ic.nrd ljw (Chrpr.r 9. Com,fttuing sirh s..ri( ?(rD uf Divtion .1 oi rhc B!\ircn "{,1Pbfcssi(rr A)d.).rrhirtEo.shc hcxcnrpr rhcnliorrtrd rlr h$i\ f(trrh.rllcecd.icnuion Anyvt'l0rtn,ofSNri.n70:ll5byr.y
<br />rppli.a nrar(rn,irsrhFcr\rhcrpplicanrt,3cirilncnrlryotfortritr.rhxnfivchudtuddollurs($5(x))
<br />-l-
<br />!s nwmrol llrcpropcny.orrlycmployces wirhw0g$rs lhct s.lc c.mFnsarion. willdo ihl work, rhc ntrtm is tur
<br />inrcidcd orollcrc lirrvlc(Scc?044,Bu\inesandPmfc*nn,\C(xlc:Th.Conk.ritr\Li.cnscLnwdocsnol.plrlyrornowncrol
<br />rhc pop.nl sho huilJs or i'lrl)(,hs rhcfr,n. i$hodrs\uch*orkhi'nscllorhc clforrhMr3hhnorhcr.wn.nrployccs.
<br />Frvid.d rhrr such imnnNctunn rr or imcnd.d or ofi.rcd tur \rlc Il hoMv$. rh. hui[in! or nnpnEnrnl t stl *irhin , n 'c $.r
<br />oicoq,bn,n. r,r Otr ncr Bui[.r willhavc thc budcn.lF)vin8 rhd hc or shc di] rct boiil or i"er& rhc tmfiy ro h. ru4r{of
<br />L asosncrofrhc nmIi.ny. rnr.rcld\i!cl!conkncrine trirh 1i..tr\.d cotrtr.b^ t) $nnru(r rhc Jrn,ic.r (S( 7l),11. Ud\ircs
<br />$d P\r!.\ir Co c: l hc Cofi.ct.r\ Liccn\c ljs de\ nor lpt ly r) in os ncr ol nrcp.ny Nk) 6u ild\ or l 'nfr.rcs rhcr.or.
<br />and who otrr.J(rs fd {rh pmlccrs wirh r C.nkrttrr\ ) lircn\cd DuFur rorhcContr.r.isl.lccnkli,w)
<br />I r crcnr u dcr Scdi(n U & P( lorriir rcrvnr
<br />Drle Owner
<br />rvonxrnsi conirrrt.srt I tor
<br />TIECIAAAIION
<br />I hcrchy !in m unncr ncnrlryoipcrjulyom ollhc nnk)win8 dalnrr'nnN
<br />-l
<br />h.vc0, will nEn rin 0 Ccnikalc of Conrcnl l. Scll. nNrrc ld sortcr' compcn\ar io.. r\ pbvidcd rltr by sarion l7m of rhc
<br />ljbor Codc. for rh. p$Lntun.. ofrhc work for whi.h rh. !.rnri i( h\ucd.
<br />Ihavcand$ill rinrai',$ort..ecomFnrari('oin\trrmc.a\rcqundhyS.crnr:17fi) frhc trhtrCodc. fitr rhc pellhrmanccof
<br />rh.sorktushi.hrhisr.rnrirrshsu.dMyw.rkcn'conlf,nsNri, trsuft..c .rriq aM Flicy nunrhcr uc:
<br />l.cnilyrhdinthcF-rlaflnrnccolrh.*o,kln$hi.hrhhpcnnir isn cd- I sh:ll tror cmnloy rny prn.i in.try matrrcr
<br />v' r\l. hccoR suhjc.r roihc$orkcrs conrf,n\rrio. h*s or C{lii(rtrir, md ryre rld il I \h'urd hc.onr suhicl ro rhc
<br />woA.n d,nFcn\nrion pn)vti{in\.lS.crn,n:lT0Ooirh.lihr Co{lc.lsla'tl, f(rrhwith.onrdy trirh rho{ !mvni.n\
<br />WARNING: t1lhtrc lo $cur! $orkcrr omp.nv i,[ covcruc i\ unllstul. rnl \hall "ohjorr m. fkJ)ci I. dimin.l Enihas a
<br />. \il lltrL\ !n 1" .nd hln,lrc(l rh,trMtri Jollar!1(x).(xxD. i r!l,lili,r rr rh. c.n o f..'nFnsdbn. drmBcr .s rovidcd tor rhc
<br />7 Bqq17
<br />rommncin! wnh S(rion 7000) olDivision l
<br />SNri,r.rl)76ol l[c Lrhtr (ix]. id.rr d_/,,.,", l/'r4
<br />I hcrcby.llnm uklc, l[nrlry ol'pcriu lutrdc. Drovi!iotrolCh4,rc! 9 (
<br />ol thc atr! r$rnd lhlc\\ortr C-(tr]c. rtrd iy lr.tr\r ^ ', tulllo'.. rftlcll..r
<br />'n::"::J b /a/lfrc /tneu/r*/
<br />I hcrcby lfilnnMcr pcnally of pcrjury
<br />i\s!.d (Sc. .1097, Civ C ).
<br />rconnrudhn h irslsemy tnr lh. perro'futc orrhj Bolk rd*hichlnn ltrmit is
<br />AIILII:ANLDICIAEATA!
<br />I llnby dnnn undcr t'cnrlly olFcrjury unc ol lhc folk,wnrS dccllrlrions:
<br />D.'fr,lnn). Pcrfrir\ A\L(.\ Norili.arion F.dfalRdEUlxriois ( firh{0. PM6)
<br />Rcquncd Ixtrcr of NorifKari)n
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsu lation ,l
<br />Rool Sheathinq (,l4Asrio-16)
<br />Shear Wall
<br />Framin s
<br />lnsu lation/Energy
<br />Drywall
<br />Brown Coat
<br />NI asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />En gineer Final Report
<br />Flood Zone Certil
<br />FINAL 1 \s \(g /./tl0l.
<br />Certificate ol Occupancy
<br />Notes B emarks, Elc.
<br />ID/SIG.
<br />Ext./lnt. Lath
<br />C"EF.
<br />-l
<br />ccditythat lhc ltdcral rqularions rc-qddin8 ashc(os rcn,vnl arc norapplicablc i{, rhi\ pn+d
<br />tr od'Mhrr I hJk Rad rln' iml'.rrnn lrl {Jrc rhJrh. ah'\t irranuri.tr is.oret. I rfN to.omtrly snh all Cnyand Connry
<br />il'\i!y'rndsiJkliurElll'nAr.hurld'necuh{rurrNn,xlh.dhyNrh.rizcrctrcscnldivcsollhhCilylndCounryk,cnrcrun nrhc
<br />.,t'""Vn-ru n. nnr t," .\nq ri,r, ru'F,.qa ,/
<br />"";,"/,",,; illt *t:ZP L-' /
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