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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.OWNER BUILDER DF]I,CAITATION
<br />I hficby afilrn undcr ItMh, or Frory rhd I m crcnpr lion rhc G, n.ros Li.ctrs tis r'or ltu nnbwing rcN)n ( se 7l,.l l 5
<br />Busincss ,nd Pidfcsrn,n Colc) Atry City or C{,un'y shi.h mqxirs a ,rnnn n, mn(rucl. nlt.r. impruvc. d.nblnh ot rcprir dny
<br />stru.ruru. prior lo ns issurncc, nlso Gluncsrhc rp/i.dnr r.r\u.h pcnnir ro fiLa si8ncd slarcmnr rhrr hcor sh. is li.ctrsL'd pu*urlii
<br />n, rhc 8,vi\io.s ol rhc Co trctr\ l-i.cnscd lxw (Chrprcr 9. Connncncln! wirh Scction 7UD ol Divhiotr 3 oflnc Busnr$ and
<br />Pmfcsions Codc) or rh{t hcor shc s cx.mpi lhcrcliontrnd rhcbasis lor rhc0llc3cd cicnrflion Anyviohrn,nofS(rion70ll5hrrtr!
<br />rptlicrnrforrFmrir\ubjccrsrhcalplicanrhrcirilpcnalryofnormrcrhnfiv.hunduldollds($50O
<br />-1.
<br />!s owrcr of rh.pmFny, or m, cm!'lores witharBcsrs lh.i $lc ompcn\art,n, *illdo rtr so* ard rtE nrlw h ml
<br />inrcndcd or oficrcd f.. slc (Sft.7044, Busiftss ,nd Ptuf.$ions C.Jd: Th. C.ntrcrols Li.!trs tiw dms nol atdy ro an o*ncr o,
<br />rhd ptr'pcny vtE boild\ or iml,.rcs l,lc@n. and Nno d6 sEh wort him$lfor hcrRlfor rtmugh his or h.t oancmployccs.
<br />nrovidcd rhal such impmlcrEnls m ml inlcndd or ofimd for slc. li ho*eEr. lhc huiuiry or i'qrownEnr ir sU wirhin oru )td
<br />ofconplcrioi. rhc Owic. Blildc! sillhlvc rh. htrdcn oi proving rhd h. dr \hc did nor buit or nllpor lh.ImIEny for thc purrDs ot
<br />z-,,soumr ur'hc |,ol)cny. trn crcluevclyconr0 '.! wnh li...s.d .Dnrncrors ro .on(rucl r,E pmicl (S( 7014- BusincsZ,,a n"tr\.on C"0". it
<br />"
<br />C.nkrck"\ I Ee;* L!* d.;. n"r apply ro E o*ncr ot pr.Fny who builds or inpmv€s rhermtr.
<br />rnJ qho conhcB lor such )j.rrs wirh! coma.b(s) li.cnscd pusurd ro rhc Conlmctols l-icctrs l!w)
<br />7
<br />!]l!!r!&!Ll!J!
<br />I hcrcby.ftnmundcr |Enrlly ot pcrtury one oflhc tollowin8 dNl.rorions
<br />-l
<br />hlvc ud will mintain r Ccn iarcare of C4nscnr h Scli lnsurc lor worlcr' innpcnsri.n. ar !,ovidd nr by sNr ion 3700 ot rhc
<br />tihor C.dc. lor (hc p$fornEncc of'h. wort for which thc Fflnir ; issucd.
<br />rhc *ork ntrwhichrhi\ lcnnir i\ isucd Myworkcrr con{'ctrrxrn,n in\trrxi(.dirr x0d fDli.ytrutrrbcrrc
<br />-l
<br />ccnilythar inrh.lcrloirmnccolihc 'ort lor *hi.h'his pcflnil is nsu.d.l shall nor cmrloyrnrllcrs,n in any m..'Er
<br />$ N 6 rt.om s!bj..r b rh. wor*ds onp.n\drt)n l,ws .r Caliromi,. tukt a8ec lh( ill should trcom subjccr t, rh.
<br />work$J com{,.ns,rion provisiotrs orScction l?0o orthc bbor codc, I sh0ll.lbahwirh comply*nh rho{ pdlision..
<br />WARNIN(;: l.nin,ir. t' !.ctr..conD.nsrrt'n.oecmgc i\ Ltrh*ful, rnd \hrl! sublNr an cnfhycr lo oi nilFmlrics trd
<br />nd dolla^ (tl(xr.(xx)r. i'r rlirio t) (hc .o{ o, .onDcnsrlror. Jrnugc\ !\ prrvidcd lnr rtu
<br />7*,/tr
<br />DICI.ABAIIIIN
<br />I hcrubyalfir uM.r lx.olry of Nrjury thd l,m lieNcn undcr Eovision ofChlplcr 9 (comtun.ira wirh s*rirn 7fi10) orDivhion l
<br />of rhc Brsincs dnd Pft,rc$bns Codc. dd ftylic.n* ic in tlll for.c axlcfltcr
<br />I Contmctor
<br />CQTSItrI]CIION.LENDAGAADICI
<br />I tcrcby !flirm ullcc, pc.olry or r.rjur rhd rh@ is r connrudion knding,Bcky r.r lhc pcdotimrrc ol thc work ttr qhi.hrhh frnnil h
<br />nsucd (Scc. 309?. Civ. C.).
<br />APIIICANLIECIITM.IIA!
<br />Ilrrhydtn under pcnalry ofpcrjuryonc orrhc n,lhwill3 dc.lfarions:
<br />DcnDliriotr Pcflnirs-AslEsros Notification redcEl Rcgllorioi\ (Tirle40. P!n6)
<br />-Rcquncd
<br />Lrncr of Norifrarbn
<br />I .cnity $ar thc fcd.rol rcAularions rcBedin8 0stcno\ rc,Dval sc nor +pli.lb|. tu rhis pmre.r
<br />-l
<br />ccnilylhlI I halc rcad rii\ appl
<br />ordinur_cs 0nd Strlc L{*sEUlinr lr
<br />rbvc mcntLorcd Uo|fny fn
<br />,\Dt)lir l,' ,\t.nl Siln lurr
<br />["*u.*.",0n",,TCWA
<br />o comply wirh rllCiryatrd Coufry
<br />:.'.'::;Iril;V
<br />Forms/Steel/Holdowns I '4-
<br />Erection Pads
<br />UFER Ground .|r _l I
<br />SLAB Floor 7 u t5 ru w
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulalion/Energy
<br />Drywall f*>'t
<br />Ext./lnt. Lath tl U\
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar l(1 I
<br />Handicap Req U\
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL
<br />Notes Rema Elc
<br />\T 0 UI
<br />COMMENTS
<br />Set Backs 6)(1r,f1^f
<br />,#d;.,,-,t,o)
<br />-{'
<br />''try
<br />Sublloor/Vent/l nsulation
<br />,2)_
<br />0
<br />v1-/
<br />4/l 'rpta414-2-t.)
<br />Certif icate ol Occupancv c, I \----
<br />or.,t- nl4T0 cdeff ?-r^'-qo
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