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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCA'IATION
<br />I hcrchy ,mrm undcr ,.n0lly of Frjur, lhar I m eicmpl from lhr Conki.oN- Lic..sc ttrw for rhc loll('winE rcx$tr (sc.70rl 1
<br />,rusinc$ rtrd Proicsion C.dc): An, Ciry or Counry which rcquircs r Fmir ro connrud. ahcr. improrc. dcnn,lirh ot rcNt my
<br />srtucrulc. prior ro irs hsusncc. al$ rcqrirc\rh. appli.anr nr su.hr.mir ro filcasismd {llcmnr rh3t h.or(hc r liccnscd luNnnr
<br />ro rhc pnivisio.s orrtE Conlricttr s Liccnscd La* (Chrylcr 9. ComtrEnciis wirh sc.rion 7u)0 ol Oivtion I ol rhc Bu\iics rnd
<br />lftrc$i,,ns Codc) or rhar hc or shc Gdxcnrfl rh.rclio'nand rhc hd\h larthc allcec(l cxcn{'lion Anyviolqrio.oisc.ri.n?]l5byan,
<br />riplicanr rorapcnn sohjc.r rhc aptlicrtrrto r .ivil I'cnalrt of rcl nn.crhm livc hundr.ddollm (s50o)
<br />-1.!\.wncrolrhcpmpcdr-ormycnDk,yLt\sirhwxgcs,\rhcn$h.o,nFNrlior.$illdorhc*orknndrhcslfl.hmlsnolinrcnd.i ororcrcil r(, $lc (Sc.70,l]1. Busirc$ Md Pi)fcsidNC.d. lh.Conrrrcktr\I-n{nrlisdocsror00dyb!nown.rof
<br />rhcrn,p.ny who bnilds or iN,ots rhjd)n. tr lqhr .cs{rchw.lthiN\cll.rhcr{lforrhmuShhisorh(owncrpkiyccs.
<br />n,.vidcd rlrr such inlr.vcnrnh urc norinlcnd.{ orcrcd nn {b lf,lx)*cvcr. rh- huikli.gor i,npmvcrEnr i\ v,ll] uirlrhonc $ir
<br />ofonlrkri,n. rh. O$1rr Built r eillhN rhl tutno oi provnB rh.r he or \hc dd nn buikl or inDn,v. rhc tmFny for lhc I!rF,{of
<br />l- $owrcrol rhc pnr!.ny. an$clusivclycontrcrin8 knh li..n.cd.onta.ror('con(rucr rhc Protc.r (Scc 7Oi-1, Bunmss
<br />rml pil,6\\bn Codc IhcC.nrr.tr'sLiccnscllsdocsnordtflyroM.$ncrolpropc yohohuildsornnprovcsrhcrcon.
<br />nnd qh..oMnchforsKhprciccls*nh!Conrruclo(Olicc.scdpulsu n,rhcCodru.rols Li.cnsc l-rwJ
<br />I mcxcmo utrd$ SNlion
<br />ul)8(!&ua!IrrNsarlo!
<br />DICI,AN.trUON
<br />I hcrcby rfllrn! uhd.r Nmlryoiptrjuy.rc otrhc roll{'sil8 dcclxrrrtnr
<br />I hivu rd will rn,inrair 0c'cnificalcolCon*nr roSclf ln\urc lor work elr .oni pcn\d io n. m Pmvidcd tq hySc.ri{J. 17(x) olrhc
<br />L&tr Cod.. ror rh. pjr.nruN. of rhc wor* l'or wnich Ihe pcnni h nucd.
<br />rl[ *o'k l(tr *hi.h rhn n n ir ir i({El Mt nukcr- cotrfctr{il i(nr iNurarc..]ricr J,xl lxllirt nutrrh.r rrcl
<br />I ccnifyrhrr i'r rhc p.rfoirMn.colihc work lorwIich rhh Pcirn]r h is\!.d,I shtllnor cnloloyrn] pcrson in !nynrnn.r
<br />s) !s to hccoaE ubj$r ro rhc *ortsi c. nrrcn\ar io. lus s orcihlnrtu.. rnd a8rcc rhlr irI shonld lKom ruh.iccr '. tlE
<br />work.rs conrncnslrionpolisn,nrofS.dn .lT00 of rhc Lrtxtr C(jdc. l $rll. lon hwilh u'mPly sirh rhoe ln)vnions.
<br />WARNINC: F:ilorc t) \c.urc w.rkcr( conrcnsorior n unh*tu1. ud \hrll subjc.t .ri cnr olcr b .nnirtrl !t rlrt\ .trd
<br />addirion ro rh. .od of.otrrrcnsrrion. dlnupcs a\ ptu(idcd f(tr rhccivil llnc\ rp t, onc hxndrud rhou\dnd dollffi (Sl(x)-U)o)-
<br />scrrn r .lr)T6 0t rhc Ilhrr cod.. intcrcsr md .rhmy*qlx lr{
<br />DIIT.ISIIIII)I
<br />I hcrchynlltm unlcr pcnrlryorFrjury rhd I nn l,.cnwl oid& ttro$n olChrPrcrq(.onnrtrui',gwihS..rirnTlXx)rofl)iri\n,n:l
<br />s (inlc tln,v liccn\. i\ i',lulllnr.critlclL\r
<br />l-iccnscChs:-
<br />ttzr: /K
<br />ll.)rsl3ri(]IllurJrDuxiLxf
<br />t hcrhy !flnmuftlcr Fnalrrorp.rj!ry rh rhsc tacotrnrudn'n bnrin8 rscrcy tn rhc Frronn.flcc oflhe work ftn trhi.hrlns F,nn ls
<br />i$ucd(S( 1097. Cir. C )
<br />knd.rr Nenr
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<br />APPLICANT DFCI {RATION
<br />I My afim undcr pcnrhyof pcirury onc oilh.lollowine dchralions:
<br />Dcmlilion Pcnnits-Astcsros Norificnrjoo F.d.ral Rcguldirns (TirL 40. P.n6)
<br />-Rcquncd
<br />L.rrcrotNorificarion '
<br />-l
<br />ccaily lhdr rhc rcd.ml r.8xl{tions rgardinB asbcslos rcnDval arc nor ,p kable lo lhk pmict
<br />-l
<br />ccnifythot Ihovcrcld rhtamltllion,.d arc rhd 0. atnt i.rornhrion is.orel Ls@ ro omply wnh t[ City !"d Co! y
<br />ordimmcs rnd Srtrrc L.rvs rclirin8i) hrildirg irucrtrr! ai hcrchy iuthorizc rc nf\ oi lhi\.ivrlt(.onDlvn) cnlcr unI ll[
<br />xl . f,nltrnnl ,rr)t{r 1v l(tr irl
<br />At,llimnl o. Aa.trl si*n{lurr
<br />Pemil&nant.(prinl): -)\LzqueC
<br />t lzo /rr+
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Roof Sheathinq 1lvqlr8 n\)/.y4)
<br />Shear Wall I
<br />Framinq
<br />lnsulationi Energy
<br />Drywall
<br />Brown Coat
<br />Nilasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL T- qo4 o ,JJA\,tLa(qv)
<br />Certif icate ol Occupancy
<br />Notes, Remarks, Etc
<br />SublloorVent/l nsu lation
<br />Ext./lnt. Lath
<br />Lf,ndci\ Addrc*
<br />tt
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