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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE rD/srG..COIHTIIENTS OWNER Bt]ILDI]R DEt,CARATIoN
<br />I hcrchy illnm uklcr Fmlry.f Frury rhai I anr cxenrpi fo,n rlrc (i)nrMtrr Li.ctr\c Lru l rhc lolk,siig rcas (Sc.7o.ll5
<br />Brsi',.r\ rnd Prolc$ion Codc) An! airy or Counry uhi.h rcqlircs r rErmir rn mtrslrucr. rllcr. imnnve. &mnish or rcpan .trr
<br />\lnrcturc, lriMlo ir\ i\suh..c.rl$ rcquircs rhc lpplicrnt lir qrh |tnnn r) liLasiStrcd nnr.'tunr rhnr h.or shc illi..h\.d pur\urnr
<br />to rrf, lr.!i\n s ollhc Cotrtr0crors Liccnscd ljw lchrprcr 9. Conmcncirg wirh Scdion 70(x) of Divhiotr 3 ol'rh. Businc$ rtrd.
<br />Px,rcssnns (irdc) or rh r hc or shc i\ crcflrpt rhcrcliun iM rhc h is rff rhc allc8cd crcn,nrion Any !iolarior o{Sccrion 70.11.5 hy rny
<br />rnpli.anr for al.nnir *rhj(h rhc (p0lic!trtto rcivillEn(lry.l nor m.Erhrn fiv. hrndi.d dollah($5m)
<br />l. * o*n rolrhc I,ropcrry, or r]y cnrl'lo)Nr sirh srscs !s rhcir slc cotr,pctrsarion. *illdo thc w.rk an,l rhc sltrhtrc is En
<br />i cidci or.ficrcd for srlc (5(.701.1. Btrsin.ss md l,rofcsions Codc] Th. Co rr.roas t.iccnsc htr docsn.r.polyturnow.er f
<br />rhc mrn ny who bu ild\ or nqmks rhcren. !(l stu dNs such x,* hin\cll o. hcFclf or rhiir3h his nr hcr own c.rrloyccs.
<br />pmvidcd rhar \uch imororcmnhEmt inrcndcd d off.nd inrek lLh.wc!.r.ihcili ing or itrltrmvcrnr t sokl *irhinnrc r!
<br />olconqrblbn.llf Owncr auiu.r wiu halc rhc b[rdco ofpovil8 rhll hc or shc did mt buiu or iryruvc rh. pmtrny lor rh. ru{x,*ot
<br />L a\osncr oirhc fl.I)cny. rrcrclusiv.lycuftrcrinE wirI licen\s] conrrcron h con(rucnlE pmjcct (Ss. ?(84- Bu\incs
<br />rnd hfssirn Codc: Thc Conkrtr\ l-iccn{e l.xw docs trot rIJrly ro trfl owncr olnropcny slro buildr or nnprovcs rhcrcon.
<br />rid *ho co ri.h to. su.h tm]c.r sirh r(,drncttr(\)liccns&!purshtrr
<br />L/llllc\cnrfl un cr lclr
<br />-J- "r 11 .Dd"1 ry 2o**,
<br />I hcrcby !fltflunds Dcnah y of Dcrjury onc ofrhc f{nb{inS dechlrtions:
<br />I h"ecud siilnui ain! Cc iti.ntcofcotr{nr t) scll lnsurc fi,r worLcn coml.trvrion- !\ pmridql Ior hyScclion.lTO(ror rhc
<br />I]fitr (()d .lor rhc a.nnnun.. orrhc wo* ror which thc Fnnil h nslcn
<br />I hrvr rnd wllln,ri0ltrir *orkc.i.onrFn!rri( r\urrrk.,r\rcqutcJhySccriotrlTlx)olrhc,.rhorC.d..rarrhcprnrHmcol
<br />rlr sork tu shich rhht.nnir i\ i$trcd Myworkcr{ co rtr \ rion i'NUr ncr catricr .dpli.tnunrh.r rr.:
<br />P,ni.1 Nu'nb(r.-l^nircs
<br />_l ccnirytnar irrhcltrr.rnrn corrh worr lar *hich rhi\ p.imir is issucd. t shrlln.r cntl.y nny r.Non in lnynrM,cr$ * t, h(rotu $h]ccl lo lhc *r*cr conrDcnsntiotr laws of Cnlitrnir. rnd agrcc rh ifl shoui h.(mk sohjcd ht)f,
<br />qork$J corpcnsrr ion proririon\ ol Sccr ion l TOO oi rhc Ll|r)r Cdl.. l shrll. l.nhw .onlllly wirh rli,$ pn,vtinr
<br />WARNINC: r.ifurc b ku. workcrJ.onf.hsario!..rcrosc h unhwlir ycr lo ainrinilpemlrt\ rtrd
<br />.ivll liri nf ni oN htrndrcd rhou{ d d.llr\ lsl(x).olDr. i'r nir i(xr. drnrScs rs pr.vid.d Lr rh.
<br />Sc.riotr l07a ol'hc btxtr Cudc. mrLrc{ M'l
<br />,,",",7 -*tt-- (U^C
<br />DI':( I,,\R |I loN
<br />I h.rht aflirn trndc. rcnallyoi0crjury lhlr I .m licn*d undcr I,ovi\bn ofChaprcr
<br />or
<br />'hc
<br />Busircsstrnd Pmics\iorN Codc.0nd nry li..nr. i\ tu ftrlltirr( xl cr'lc.t
<br />'ntrf,mi'rg
<br />rih Sccri(in 70(X)).lOn ni,in.l
<br />SIINSIBUEII!}NI,ENDINC.&GDNCT
<br />I hcrcby iffi n unJur Fnalry or pcrlury rhd rhm is ! onsrruction bnding trs.ncy for thc I'.'ndrmrcc of ihc wor* fo! which thh lcanit is
<br />issucd ls.c.:rO9?, Civ C )
<br />AIIUSAIiLIECI,AAdIION
<br />ItEEh!nrtlnnu*idr |*Mlry or p.rjur! onc orrhc t0ll,,$ltrsncchDrn \:
<br />Octrblni( Pcnnns Ashcdos Norific,rion l:cdcrul Rceuldir r ('rirb4t), Pin6)
<br />Rcquncd krrcr of Norifi crri0n
<br />-lccnilyrhrrrhcrcdcrdlrcguLrn,s
<br />rlrdingr\h((o\ rcnmvilrrc n.l aptli.rhlc to rhn tnjc.r
<br />lccnifyrhar I havc r. rhi\ inth.dionml{atc irc.r I rsic ro.oDdy wirh allCirv rnd C,nn v
<br />orliMtr.cs Md Sr rc l, w!rclaritrgr.6uitnr8.on(rilc rrt)rc\.trrdnc\ ofrhis Cirv,'nd Courry (, cnr$ unotr rhr
<br />xhovr nrnriorcd prorcdy |or st$lrotr NrB$c *;'- -rf-,Appli.lnl o. Aa.trl SiAtr.lurr
<br />lvwa i%_
<br />Set Backs
<br />Forms/Sleel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulalion
<br />Roof Sheathing
<br />Shear Wall I
<br />Framing w o//e 4q D
<br />lnsulation/Ener r/*,Jv ;)
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lvlasonry
<br />Pool Fence
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL ///7il/ .&4o
<br />Certiticate ol Occupan
<br />Notes Remarks, Etc
<br />('rrrr
<br />-
<br />Drywall 9/z
<br />T-Bar
<br />Handicap Req.
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