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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns 7.2 ,,- D DO
<br />'lt r,,/
<br />UFER Ground td "l)t
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq r',L lD ffera
<br />Shear WalL 6/it / t.6 rq 16
<br />7/1/r Ala,alr., o{Framins "/*fi4 Y;\<-"to' Pisr-/r<atI nsu lation/Ene rqy r'ftp1
<br />5[\Coa,tzrrt"i lo Erq+Drywall /0,/-.t
<br />Ext.flfr'D Lath lu/4ltg Stt/]x '/ l%K
<br />Brown Coat
<br />It/asonry
<br />T-Bar
<br />Handicap Req.
<br />Depuly Final Report
<br />Enqineer Final Report
<br />5l\*r.?aaor*
<br />/.,
<br />FINAL | -q -zet YWa))
<br />Certificate of Occupancy 12 '\Z
<br />Notes, Remarks, Etc.
<br />OWNER AUII,DER DI'LCARATION
<br />'I hcrcby aitm x.dfi r.nolry oi pcrury rhar I dh cr.'npr rorn lhe Conrracod Ltctr* Llu rin (h. roll.eins*a$n (Sc.70ll5
<br />Businc\s a l Prolcssion Codc) Any ciry or Counly shich .equito\ I ,cann I. .on{ru.r' alrtr. impro,c. denolirh t{ rcrlir unv
<br />irucrur.. prix ro irs hs!!ncc..lro equncs rhc artli.lll ln. snch Frnril b rilc ! \is d {arcmnl thar h€or she i{ li.ctrsd Pulsu l
<br />x, rhc pmvhi.trs ofr}E Co.lrocrq s Liccnscd uw (Chdlrcr 9. CoDkn.re Pirh Sccrio. 7Om.r Divisi.n 3.r rh. Burin'\( 'nd
<br />PbrcssionsCodcrorlhrrhcorrh.ircrcnqthcrc,iomandrhrtn\hnnrhcallcscdcxcrprion.Anyvidclion.fsc.rirnTO.ll5t'vanv
<br />umlica lo.0Frmir \rhjot lh. lpplicanr lo a.ivilFtrxhyofnol nnrc rhli 6v. hundtcd nolkrs (5500)
<br />L as o*n.r ol thc rorcny, {tr nry.nDloyccs qirh wa8€s !s lhcn sulc .ornrEnsal ion. will do rtr *olk drturmr@i\ml
<br />irldxtn or ottcrcd ror uk lss.7o14. tsusincs and Pror.\si N colc 1 hc Cont,ch\ Licctr* tjq docs tror opPlv lo d' owncr ol
<br />rhc p6r.n, w}x) hrilds or impm!$ Llcdn. dd wh. des u-h *o,l hinN.ltor hccclfor rtn,uSh his or hcr osn.mpl.yccs-
<br />providcd rhar such i'qmEnE h m rer inknddl or ofictud for $lc ll hoNcrcr. rhc huiuing or inl,orcnEnr ia $B within one Fr
<br />olclDdclbn- llE Owner Bui*]d qill h.w rh. hudcnoflbving rh lE or \hc did rtn huiu or n\()t rh. PmFny for rhc NtIn{ ol
<br />-1.
<br />rs owrE ot rhc pnD.ny. an cxclusircly conr,acring eirh li.cnscd contrckB tu oNlrud rlE Proid (scc 7()44. Ausim\r
<br />,trd Pi,tassirn Codc: l-hc Co.kr.iofs LNnsc Lrq docs mr utPly b .n ourcr oI trcp.ny who buildsor i'nFovcs lhctcon-
<br />ond eho onr.dck f{tr such lmrrh *irh a ConrBcbng ltened Nrsurnr ro rhc coDlroclois l-i..ns. bB).
<br />-l
<br />urcknrpr uhdct S(l
<br />WORl(FqS' (:(TMPENSATION
<br />IECI,Af,AIION
<br />I hcr.$y rfirmlndcr pcnalry ol p.rjury o.c ollhc follo*iis dela,liotrs
<br />-!
<br />hdvcrdwill minroin r Ccn ifi.ate or co nscnl to Sclf'lnsurc ld workcn conrr..sarion N ptuvided tu bv S.crion:l?(xr ol'rhc
<br />tibor Cdq aq rhc pr.rorrorcc of lhc slt 16. which
<br />'hc
<br />pcrmir i\ isslcd
<br />Au;rnd willmlinuin workctr conrpcnsdn,n insuratr.c, as rcquncd hySccri(,nlT(x)ofrhc l;lhor Ord..lor thc Pcrlorntu& ol
<br />:\tu'mnctr!xri, ntrrnr..rr"c' rril
<br />-l
<br />ccnily rhar in rhc Frfurmne olthc Nork for {hich rhil Frnrir t issucd.I shrll tror cmplov rny p.rcfl in.nv mMnfi
<br />s' aslo bccom subjcd ro rhc qorkcis comFnsario.lows olCnlili,ru nni aEE rhxr irI should bccom bjcdb'h.
<br />wolktr{ conpcnsarion nr.vi\ions oi Sccl ion 3?Oo of rlE ttrhtr codc, ! shull. tonhwirh omPlt w irn rlt,t ptrvisio.s.
<br />WARNINO: Foilurc ro ccurc $ortc .onpc..ariotr covcruac ir lnlawhrl. and sh0ll sxbjd rn cmllo)lr lo cdn nar Pcrullis lnd
<br />n) oN hun{lrci rhot\rn.l doll addirio ro thc c.{ o{ comp.nsdion. dlnugcs as Proridcd l'or rhc
<br />DECI,A.BAIION
<br />I hcrchy !firmhdd Pcnnxyollxriury lhtrr I rft liQnk{ undcr Provhion orchaplcr 9 (comnt irr! wirh Ssrion ?000) "r DNi\ion :l
<br />of rhc Bu\iDcs\rtrd l'rofc\lnnr Codc my liccnsc h in lull rofrc md cr'lc.l qqu55\
<br />\
<br />I lmhy allirD undcr IltMlryol t^*rjur y rhd rhcr. i\ a con{r.ri)n Lndirg !3. ty li,r lhc Pcrtrnuncc olthc work tr whi'h Ihi\ Pcnnir is
<br />n\uo,l(Sc. 111q7 aliv C )
<br />APPLICAi\T NEcl ARATI(}N
<br />I lErhyrnmrr dcr prtr.lry oft'crjury onc orrhd iouo*in8 dcclorari.n\:
<br />Dcomliliotr Pcnnir\ Asb.sosNotili.orion Fcderal R.!uhrnrs(Tirlc40 Prn(,
<br />Rcqutcd landr ot Norifi corior
<br />I.cniiylh rhc icdcralmgulrrioN rclrdirg a\h.{o\ rc'novrl.rc norlPllic l,L n,lhr foiccl
<br />ccni,ylhirlhaldrcadrhisr!Plicrlionandd!rcrtu rh.ih,vc irrionDri{nr is.orcd lrstero.o4,vwnhollCirvnndCounr!
<br />f.cs {r(lsrrrc i x*\ rrh.rcprcse dnc\ otrnt Cir
<br />)'
<br />xlxrrc nrnri(nrJ ln,lf,Iy inr
<br />ro buildin! con{rucrn,n. rtrd hcr.bl
<br />rrA5 d4tr
<br />Erection Pads
<br />Pool Fence
<br />Flood Zone Cefiif .
<br />|o/ft/ F{
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