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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DI.]I-C.^RATIoN
<br />I hcrchy nmfln undcr p..alry o{ t'criu! lhal I an cxcnpr lmm rh. c.ntacror' Liccn* ll{ ror rhc lollowin! rcR r (scc 7031 5
<br />Buincs and Pmrcsi.n Codc): Atry Cily or Counry {hich r.qon$ I Jrnnil ro .anrdru.t. ,lrcr. iarl'rovc. dcftrlish or EIrt mY
<br />\rn'crurc, pri{, t, ir\ issrak_c. llso rcquirc\ rhc applka tu sx.h Eirnit lo llLa lign.J eatcrrcnl thlr hcorrh. s li(cnscd ruNanr
<br />ro lhc pmvirions oi rhc Conrd.rds Li.cnsd Llr (Chaprcr 9, Connncmins !irh Sc.rn,n 70m ol Divniotr I or (rF Busincs tnd
<br />tn,fc*iois Cod.).rrhar ncorshc iscxc'npr rhf.nonrnd rhchsis ior lhc rllcgcd.xcq)liotr. Anyviohrn ofSdjonT0.ll5hlany
<br />Jpplicrir ror . lE.rnir suhFcrsrhc llplic,nrhacivilrcnaltyotnoln,crhMllvchuMrcrldollar\($5lx))
<br />-1.
<br />!s ownf or ih. ffolf,ny. or my cnl)hres wirh wngcs ,s rhcn sh comPcierion, will do rhc uort dd lh. (Brurc h nor
<br />inr.nddr oroficrcd lor slc (Ss.?u-4. Businc*and Pofcsions Codc: 1 hc cl nctolsLiccnscliwdocsnor{Plvk,dn.w0.rof
<br />rhc pmlicny who huilds or inpmws tlENn. uM *h. &rr sclr mrk hnnscllor h.Ncllor rhtur8h his or hcr o*. c.li)ll)vccs.
<br />ptuvid.d Ih{ such in[mwnrnh m o! inrcndcn orofit.d t,t qk ILhouNirhct ildingor inllovcrenr is eld wirhin nc ttrr
<br />ol dnntlcrhr th. Owncr Auilds will h.!c rh. bordcn of ProvtB th.l lE or shc did nor build or inrFow Oe pbFny for lh. puqr,$ of
<br />l.,sown!ofrhcpropcny.nn.r.lusivclycontuctilan'ilhliccnscdcoM0clorroconntu.'rhepdirrlscc.?0.Buiir'cs
<br />Md h.tssi,n Code: Thcconrrclois Liccnsc Ldt do.\ nor,ft'lylo $ o$nct ofproFny trho nuits or nnprovcs lnerNn.
<br />dnd shd ontmch for such noi{t wirh 0 Conhdono licenscd Pu'\ratrr ro rhc C.nlracrq s Lkcn€ tjw)
<br />WOR(TRS' (:(IMPFNSATION
<br />DFCI AfuTI(IN
<br />I hcrcby aiirnundcr rcnalrrortdjuryonc of thc lbllosins dcclttlrions
<br />-l
<br />hoE ,xl sill minlain a C. inc.r. orConsr io Sclf.lnsurc ror wo,kcd .ont nsalion. ss p,o!jd.d lor by Scclio.1700.rrh.
<br />L.hor Codc. for rhc Frrolrrjfrc ol thc wort fo. which rhc Pc.mn n isslcd
<br />I hlvc lnd will mrinlai, wdr*.6-compcnsarion insur!tuc. !s rcquii{ by SLtrio. .17fl) or rh. Ijbor Codc. ld ih. p'rtbromc or
<br />rhe worl thr *hich rhi\ pcmrn is isucd Myvorkcls .otr,tx',\dn nNtrir.c crmcr I tx,lty trun$.r ur
<br />P"h.yNutrrbcr-
<br />tSlt1-tg
<br />CONIIBIJCIAITLENDINASGEXCI
<br />I h.rbyantr undcr lcMltyotFrjutyrhd rherc hoon(dcrion kndinS ascocy for rhc p.rronrtrnce ofrhe *orl ror*hi(hrnnlemr n
<br />k\ucd (Sc.. 109?. Civ C ).
<br />APPLICANT ND(:I ARNTIoN
<br />I hcr.t'y dfi rmundcr p.n0lry oi pcijury otrc ollhc IoUowirB dcclarurnrn\:
<br />Dcrnnlirinn lc'm {.,\\bcn.{,hili.Jri,1' l.do,'l R.3ulJr'cn., l lc 4l Pu r6'
<br />l/-ncqurcd Len€r ur Norin.dri.tr,
<br />./4alccnrlrrhJtrhclcdcEr'cEhrn,n\RErdrtrso\bc{o.rcm\rlrr { umhcJhh ro rha nrur.r
<br />2 (d [,hr Ihr.rc. rrn.rrrr.
<br />lldinrRc. rnd srr. Lrtr( rcLrin,r tr, hdi
<br />ltxilc nf,nrn,ncd polxnl tu ir\tEri,n)
<br />ionrd arcthar rh. lh)vc itrlbrn ion i\.otrccr Is8raroLrniPlywfhullCirymdCt,rmv
<br />,dh.rizc rcprecnrarirG ofthis Cily ond Counryto..rd ulon rlE
<br />Al)Dlicm! or A!.nl Sixntrltrru
<br />r'""rir"r mnr rprlrrrr: K i,/6 ,,,," ' 8-/1-/E
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Ereclion Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVl nsu lation
<br />Roof Shealhinq
<br />Framino
<br />lnsu latio n/E nerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certil.
<br />FINAL tolr(t(9,,t-ca.zrl -)
<br />Certif icate of Occupancy
<br />Notes, Remarks, Etc
<br />-+
<br />Shear Wall
<br />I mcxcnlpt undcr Sd joo-. B. & PC Io.$G Rannr.
<br />Drr. O*ner
<br />-lccnilyrhlrinrhcp.rfoirMmcoirhcworkfdwhichlhrs!c
<br />nil is isucd.l shnllnol cnrplov lnvpt^on hanv nMncr
<br />$ N ro hc.onE sul,jsl l. lhc workuri .o.Ucnrar ion laws of Calihn,il trtrd .se I har if I sholld bc{otr $bjccr x' lh.
<br />workcn compcnsrrion povhnrns ofss-rion 3?ul ol rhc li&tr codc.l \hall. lbnn*nh.omply wirh thos PrcvisidF
<br />WARNING Frilur. to *...urc worltcB .onr!.ns rion ovcriSc is unlawhrl. ,kl sholl sutjccr m c'npk'rlr io simiid Ftu'lri.s,nd
<br />civil fincs up ro onc hrndrcJ rhousand dollar (Sl(X).O(x)). in rd irnr ro rhc con or cofrp.nsario.. dlmaa.r 3r Pr'vidcd r'r rhc
<br />s(r'cn lu'oor rhc Lrhfl c,ii". nr..c n ild rrnrmy'. rm. I ,'1
<br />*", 8-/113 ^,,,,-,|;Ar,lffi./ 2
<br />|a:CLA8A.ION
<br />I hcrh, alfiimnnd.r pcnrllyolpcrjlry rhur I r li.cns'd undn !o!hn,iorChi|)ld 9(omrcrctrs wirhsccrior7tu0r nrnirni'n' l
<br />of thc Busim$atrd Pnn qsionsCodc. di my liccnsc is in tullbie lnd citcr
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<br />l.n'lci\ AJ.I..(
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