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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUII-DEN DDLC RATION
<br />I h.rcby,ffiirn lndcr !.niky of pcrtry rhd Inncxcnrfr liom thc C.nlracloF l-ic.nsc t-aw fir rhc folbwin8 tc v,n (Sc( 70.115
<br />Eusincs rtrd Pro,6\nrn Codc) Any Cir, or Coul, *hich rcqtrn.\ r Il(rmir ro .on{d.r. rkcr. imtnnc- ,hn{,lnh .r r|Jn anJ_
<br />srru.rurc. pri{xr{, irs issnncc. also rquncsrhr Jl)pli.rtrr lar su.h p.nnirto nb a \isncd {rrcmtrr rhtrr l[or sh. k liccnsd Punurnt
<br />ro rhc pmvisions nfrhc C.ntlckn s Lienscd tn* lchtrtlcr 9. OnnnEming wnh Scdion 7t{X) of Uilhion.l of rh. Brsirrc\s.nd
<br />Pnnissn,ns Codc)orrhal hcor\hc i\crcoFrrhcrcfRnnnnd rhr hr\i\ Lr rh.nllc8cdcrcmprion Any li{fir ion of s.cri, 70ll.5 hylfy
<br />llplic irfr"p.'n suhjc.* rhc amh.nnrlon.rvrlpctrrkyoftrol m.rc lhln livc huftl!.d d.lh (S5Ul).
<br />-1.3so$ncrofrh.nmFdy.(rn1y.trfk,yccswirhsx!r\a\rh.n{,b.onrErsrrion.sill,loitI*ork
<br />]drh.{mrurck.ol
<br />inrcnlcd orolTcr.dforsnlc(S(7(}1-1.Busincss0ndhofe$ioNCodc'l'hcC.nka.roCsl.i..n\cLtrsdrcsnorryalyronoosn.rof
<br />rhc pmFny who huild\ or inqrDvcs rh.B'n. arxl *lxl dms \ach k,'l hi'r\clf or hcr{ll or rhrnrgi nh or hcr o*n dntloyccs.
<br />FrvidcJ rhrr strch nnfov.rmnrs rc trrr ir cxlLt or .ltaRl hr rJc Il lhrrv.'. rhc huikli'B or injri(,vcnr r i\ k)ld *irhn orc )ur
<br />ofconrkrion- rtE Owrcr Buithr sillhavc rhi hordcn ol lflrvh8 rkr lr.r \hc dtu mr huiklo' impmvc Ihc fnil(iy ltr rhc Puqrc of
<br />L a\ o*n.' of rhc Frcdy, a r cx.tusnrly c.trtr.iir! * ilh li.cn\cd cotrtr&l{r\ r{i cotrifl.r r}f, Pr+d l Scc. 7(}u. llunnc$
<br />rnd Pn)lc$t,n Codc Thc(nntrxcr{r'sl-iccnscl.,q.k,csn.rrpplyror owtrcroffopcnywho huild\o, inrpr)vcs rhcrcotr.
<br />rtrd Rh. Llnrmcr\ntrsuchtn,,c.ts sirh.Conrado(\)li.cnscdpisuonr brh.Conracrtr l Li..hc Lru)
<br />I mr.x.mfr uidcr Sccrio
<br />uaf,f,E&u(aMPrNsAl&!
<br />DDCI,IBAIIO!
<br />I h.rcby amrmx.dcr p.nally orp.rjuryom.flhc lolnrsin8 dsl.rrlio.s:
<br />I hrv. tuxlwill Nrinhin rCcnific0rc.lCo.snt ro Scli ln\urc t(, s.rk.* co'np.nsdion..\ Drovidcdfo'l,ys*rionlTmollhc
<br />lf,bor cudc. ror rhc p.rrormna of lhc wort for *nah ltc I'cnn i\ nrkd
<br />I i*r u.d sill nrinrrin sorkfr .omo.ner ion insumme, i\ icquircd I'y S.rrn,n .l7m of rhc bt{, C c. lor ln. Frfoht.i.c of
<br />rhe *ork for which rhisr€nnir is ksucd MyworkcE con{rcrsrlior iNur0Nc c,ric' ,ndroli.ynun$cr nc:
<br />t*alt t*rA
<br />^.,*''-gZl3SY
<br />l.cnifyth.l inrhc p.rfo!rotrc oirhc work lor $ hich rhis l.onir is issucd.I shtrll nor cmploy lny pcd.tr trtrym.nrcr
<br />a, r\bbccom \objmr rorhc work.rs ..nrFnsdior l.wr of Cdlifoarir. andasrerhnril I dFuld h.com uhjcclrnrlI
<br />wortcF compcnsrtion ptuvisiotrs of Sdi.n 3700 of rhc L txtr Codc.l \hrll. fonh*irh.omPly wirh rhoc Eovisions
<br />WAiNING r,ilurc Io Nurc workcF conucn\dii{ .ovcrasc ir utrhwrnl. and fioll suhjd !n cmpk rr ro diminil Pdullics ond
<br />.rril fircs uf n, oDc [tr r.d rlrotrsxnd ,!olh^ l11rxr.{nx)r.r oi compcnslion- dr u,Bcs .s providcd nn lhc;:'jF.l{:':
<br />,rto-_r]
<br />I hcEbyamrnutolcr pcnalry.r,rcrju., thrt I am li.cn$d und.r pmvision olChapls 9{.onmn.ine wirh Sccliotr 7OO0) ofDivkion.l
<br />oi lhc ausi,rc$3nd Pmlc$io.\ Code. ad nyli.enrc ii in tuU romc and cff.ur.
<br />P,IDNVG
<br />g AG L
<br />I h.rhy rfllrn undcr |rcMlryol |r jdry rhtrr rhcE t r mn{ddk'n hMin! o3cncy fo! rhc IErtitrmanc..frhc sor[ hr which rhi\ Pcnnir i\
<br />Lr dcir Addr*!:
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<br />APPI.ICANT DF(]I ARATIoN
<br />I M)y nnnuBlcr pcno[y olpcljlry onc oirhc t{,ln,wing dcclMrn,ns:
<br />Dc x,lti{)n Pcnnt\ Asbcnos Nolilicilion ljcdcr!lRCBUhrnnN ('firl.40, Pxd6)
<br />R.q!i'rJ Lrrr.ror Nd li.drlr
<br />-l
<br />ccdifyrhlrih.ltdcralrcsuhrnnN rcg,rdnrg Nh.{or rcnn,lalffc D.riPnlicrblc k) rhis lmi.r
<br />!4l.cniryrh lhdrcrc0drhisatplic{riorud{rrcrh rhc rh,vc i'rlarnhiotr rconccr lrsrLtt)comPlysirhrllciryrndconnly
<br />'trdi nmcs d sr.rc t$s rcli(ing ]xltur.hrnurho'izc rcJirc\cnrrri\.\ olrhi\ ( iry rid C.urryr
<br />rhrr Dur nnul lr)Pcd, f(tr i'n
<br />0 klppliutrl or As.nl Sisntrturr
<br />Y eillr ttl/i
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Rool Sheathino
<br />Shear Wall
<br />Framing >t31
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />l\4aso n ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL a /k/rc 6 b7a
<br />Certilicate of Occupancy
<br />Notes, Remarks, Etc.
<br />Set Backs
<br />Sublloor/VenVl nsulation
<br />ct-/f /1./
<br />]1
<br />hsu.d (sd. 3097, civ. C ).
<br />trndd \ Naft
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