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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILT'ER DET,CARATION
<br />I hcrcby trriirm o .r pcnllry ol pcriury rhal ! icxc'npr f&nr rh. Conr.dos Liccnse h* lor rhc f.ilowing rc0son (Scc.7oll5
<br />Blsincs a l Prorcsion codc)r An, Cny o. County phich rcquncs a pcrmir ro .on{rucr. .lr.r. rmProvc. dcnmlish or rnrn xny
<br />srrucluE. prhrh ns i$uotrcc- al$ r.luncs rh. applicanr lor slch Fmir ro ilha si8ncd natnrnl rhar hcnr shc h licctrscd Punu0nl
<br />ro rhc rovitnnN or thc Conlmclols Licen*d L{e (Choplcr 9. Connn.n.i.e wirh Scclion 70u) of Divnion I orrhc BusnNs.nd
<br />Pmlesions c{ldc) or rh h€ or shc i\.xcnDt rh.r.rro randrh.hask()rrhcallcgedcicsflion Anyvhhri.nofS$tion?(,1I5hyrny
<br />lpplicanrtnrpc.nrirsuhF.hrhc,tplicrntroacivilFnrnyofnotmrclhanfivchundEddoudllSS0o)
<br />l.asown$ofrhcpmFny.oruycnrrn,)e\wirhwuscsJ\rh.irslcconD.treln.wldolhcwo.[udlhc{tulurcnmr
<br />inrcfttn or olttrcd lhr sle (S.r ?O{.,1. Bxsnrss and Pmf.sbns Codq Thc Cotrtscrois l-icensc tjw docs.orlPply to tu owncrol
<br />rhcrml)(ny whr ttrilh or nrumrs rhfrtrr. od who ftssudhw,rkhinsclfo,turcllorrhronabhisorhcrowncmlbycc\.
<br />prclid.d iharsu.h nvr,rcnEnh nrc ml inrcndct orollcd lnsak lt h,w.vct. rh. buildinS or imDntmnl is \old sirhinom )t
<br />olcon{'hrh.. rlE ostur Buildcr willhnvc rh. burdcn.rpr,vin! rhr hc or shc dA ft'l buib or impx,k lnc pmFny for ltE Puqn$ of
<br />-1.
<br />a\os,n.rolrhcpropcny, r r.r.lusivcly.otror.ri|s wnh li.ctrscd (onrricir\ k).otrind rh. |Yor$t (Scc 7(!"1.llusk$
<br />r l Pirnasi Codc TltContrlclois Liccn\c In* docs norrpplyb owftroItroltcnywho huild\o. i'nP(*t\ rh$drt.
<br />rnd trho conrracr \ f{tr su.h Piol.ck Eir h n cotrtrkr( \ r tNnscd ltrnur|lt n, lhc o)nrrrror r Li.cnsc bw)
<br />I rm.rrar|, uDJ.r Scrri,)
<br />Dul.: Own€r:
<br />w( TRKUILS', ColtlPl NSA',t()N
<br />DECLAAA.IION
<br />I h.rcbyrrfinnun f Dcnrlryorpcrjuryoncollhctoll,Ninsdcclarsli{,ns:
<br />-l
<br />harc drkl will Nintain r Ccniftlrc olConscnr r. selfln\xrc rd workcH .ompcnsarion. a\ rmvidcd nr bysccliotr S?LO olrhc
<br />L.htr Cod.. r.r (hc prrlornDncc ofrhc wor& lor *hkh rhc Frnir n nrucd.
<br />,l hrvc rnd s ill Drinl! ir work.^ .onIcnsd i,'n iNuritu.. rs rcqtrircd 6y S€i i.r ]7m ot rh. hbltr codc, lor lhc p$aonutuc or
<br />rhc wort f.rshichinh Fnnir i\ issxed Mysorkc^ .o Dcntdidr insuruncc.o(icr a' B,li.y nunlh$ rc
<br />Poliry Numbcr:-Expires:
<br />l(nify rhr hih. Nrlo.mmc ol rhc s ork l'orRhichlhh pcnnir is i\st.d.l \h!ll or .nDk'y int 0.r(,n nr rny 'nrtrmrn) $ ro h.comc sublc.i h rhc workcn comtcn\xrion l!w\otCnliftrnii. nM rgrcc rhrlill \h)uld tf,tor[ luhJt.r h rhc
<br />s.rkc6 conD.nsiiion provhionsofS.crn,n.lT00otrhc I-rtxtr Codc.l shdll. ioahwili corr0ly +'irh rlxrt rrtrvisi(rs
<br />WARNINC: Flilurc tr \c.ur w(trkc .onwtrs,rnm..vcrn8c rs unh*hl. rnd \h,ll nrbjd.r trn cnrrloy.r to crinri'rl Pcruhis rnd
<br />Sc.rnr.l{)?6.f th. trtltrA)dc, i .rc( droary 1,.c
<br />7so1 1 t aDpli.onrl
<br />I hcrchyunnm utucr pcmlry olIrrjorr rhd Ln liccn*l undct t,ovision oiChuplct I (commnci.s wirh sLtrion ?OO0) olDivi\n'.l
<br />or rhc ausimss rnd Pmfesions Ctdc, dd h, li.ene G in rull r.r.. n rl cficcl.
<br />L
<br />c 14
<br />I hctoby dftlnn ridfi FMllyof F jurylhal lhcrc i\ a onrlruclion bndios asci.y Lr lhc lcdnrflurcc orlhe *orl rot *hth rlis lco n
<br />hsucd lscc 3C97. Civ C.)
<br />A.TTLICANIDIISIANAI&N
<br />I trrh, dimr undcr N.rlry orpcrjryotrc oirhc iollowinB dc.li6rn,n\
<br />Dcmlirion Pcmils Arb€sro\ N.rificdbn FL'dcnl Rc8ulxrio s (lirlc.I).l'!d6)
<br />-Rcquired
<br />LcI.r ol Noriatnrinn
<br />I ccniryrhrr rh. r. crrlr.!uhri,)trrrcErili',9 rsh(n.L'tnntrrlrr. norxptli.lhlc t) rhi!!rr'J!.r
<br />iiyrhal I havc rcnd lhn0pDli.rri{n' rid nrrc rhrrrhcrhnr iiturnrt.tr il..nccr lagrloconyly\irhrllCirytniCouniy
<br />i('n.rwlhrrcbyrdrhorizrrcprc\cnr ivcrofrhnCilyandCounryrocnrdtr|n.lrEs rtrd srdrc tiss rLlirE ro buildirE co
<br />rhi)vc nrtrri.ncd nn)pcdyln i',
<br />At,plient or A8ent SiBntrt ,",,,1/roll\
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsulation
<br />Roof Sheathinq ( 4/,
<br />Shear Wall \,;
<br />Framing
<br />lnsu lation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Il4asonry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />@1)
<br />FINAL 7411s ?,?s'ut AY
<br />Certiticate ol Occupancy
<br />Notes, Remarks, Elc
<br />cnil firc! up ro onc hrndrrd ihuusdnl dullrr lsl(I).Ul(r). irr
<br />Lcndci\ Addrcs
<br />T-Bar
<br />Flood Zone Certif .
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