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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARAIION
<br />I hcrcby rfii.n undcr F rlry r)f f'crjrry rhrr I d ercmfl fonrhe Codrn.t,. L,c.nsc trs r.r thc n hwirS rcrsotr (S{70r15
<br />BusnEss !d ftolcssion codc) ny ci'! or counry whi.h rr\tunc\ | pcirnir ro .onnd.r, 0lrcr. nnprovc. dcnFlish or rcp.n any
<br />nocture. prir to ils hsuakr. iho rcquncs th. ipnli.nnt lor su.hpcirnilto filc. ii8ned n!rcmnl rhlr hcorih. n lienrd pur\uanl
<br />to lhc Fovnnnr ol lh. Conh.rofs Li.cnsd tlw lchapr.r 9. Comnrmin! wirh Sc.rio ?0( olDivniotr 1oflh. Burincss and
<br />Pnfc$ions Codc) or lhar hcorshc is.x.mDr rhcrcnorn rhrsisrorthctrllcgcdcxcmprion.ADyliolarionolSNrion?0ll56yany
<br />appliqnl for ! pcrmil subjccts rhc 0palicinr l. 0 civil l)cnrlly of ll, nMdhntr fivc hundrcd dolhs ( S500)
<br />l, \owi.rofrhcpR,Fnr.ormyc'npk'tcc\wirhwtrlc\!\rhcn$tuconf.n\Jrion,sill o rh. aolk rxl ihr {tu1rr i, trur
<br />irlctrdL\l or olfcsd tur elc (S( 7044. BusircslrM Pr)fcs\ior! C.,lc lhcC.nka.roas l-iccf{ l-r*doc\ nor lPtly k! rno$nqof
<br />rhc pDltny wlhbuild\ornnt,n,vc\rhca)..0trduh.d..sqEh*o*hirn$lt.rhc'{llorrhx'ughhhorh.rosncn!rryc.\.
<br />prt)lidcd rhr $.h nnlmvc'nnrs rc nor inrc'd.d or o,IcKl f{n {lL ll. hoRrvcr, rh. buiktir8 or imlntrcmnl i\ eld qirhin',ft'r!.
<br />or .onDlcri ,r. thc owncr Buildcr sill hrrc lhc h dc0 ol |n.!nB lhd h. nr sh. did tror huild or illpmtc lhc ln,Ilny r'o! lhc puqxE or
<br />l.rs,iwncrolrhcpn,pcny.arrcrchlivclycoDkrcri,,!rirhlicrn\.d.okrdnskr..tr{'xcrrlfPmlcd(scc7()1]t.liuiDc\\
<br />okl hnlLssiin Cldc TlEContdcl,tr s Liccosc lns'(locs nolrnplyt. nnosncroiprop.rryrho hild\or impi{)vcr rhcr.Dn.
<br />dd *ho conhck la! \uch Ficc( *irh r Coikacron s) lic.iscd purumr k, rhc C(,nrk(tr s Li.cna. tr$)
<br />I nn,errnpr undcr Sccr
<br />]IaAKDB!:.(AUTENIA.ITAN
<br />I)TCLABI.I]ON
<br />I hcr.by rlTt ru cr pcixliyof prrjury.ncof rhr tulk'singdcclrtrri,,n!
<br />Ihrvc! {ill u'i rinsCcnil€rrco,ConscnrbSclllnsurcInrworkc^ co'np.n\arnn,. rs trovidcd rirhrS..rdr.l7(X).1thc
<br />Iihn C6lc. ior llE ocrlornrancc ofrhc *o* br uhich rh( pcnnir i\ nsucd
<br />_lhlvca sillnuinlrinrukc^conrpcnslrionin\urr.c..a\rclun(lhyScclion.l?Ol)orrhcI.rhorG)dc.nrrh.rcrrontoNdol
<br />Frmil h hnrrl. Myworkcn .on!.n{lnin in{mn.e .sricr anJ R,lt\ numhcr 3rc:
<br />Q0fr
<br />0(.t-0t-I0i1o
<br />\ ccnily rrrr irr rrrc ncai,nn.n c orrhe work ld *hf,h rhrs Jrnnir $ isnRr.I shnllnor.nrnroy !try ncr$tr lnynr nicr
<br />{i r\ t' bcco'rc \uhjccr t, rh. $rr[.r! co'npctr\]rion lars olCalilan,ix. md 4R rhrr ii I \)a,utl h..o'm {hjcd roth.
<br />sorkcr\ c.nrli(n\rrioi fovisi{'rs ot S.crtr .UUl of rh. l jhtr (i c. l shd l. tunh*irh $ lll! sirh rhos ln'vhions
<br />BARNINC: tuilurc lo surc workcrs <nqrcnelion covcrr8c is utrlatrtul. Jnd shnll suht cr rn.nrpbtcr t, dnni'kl pcMlrics aM
<br />fi'.\ trn ro onc hund'od rlnu\rn,l ,lollr'r rSl(xr(xx)). ltr x(1(lirion n) rh cr{ ol .,i mpetsarion. dsnrEcs 0s lrnvdcd lor rhc
<br />.rlr76.lrh. t.rhtr (iilc. idcro! rrlrr ;i,k"\**I rt[u.
<br />I l*rbyafllflnuMcr lcDtrlryofpcrjuryrhd l0m liccn$d undcr tDvniotr ol Chopler A (o'nmmin8 *nh Smrir. T0mr ofDilkion l
<br />of thc Busiftssand Pn'rcsions Cod., rnd my li..n* i\ in fxllfoicc aild clTd
<br />B 5.)51-61
<br />ta$iltrlcu0rrt[NluNcra[Ncr
<br />I hcrhynlftd uM.r Ffrhyofpcrjuryrhar rhcE i\ r consfl.rirtr lcndirr n8rrcy ior rhc pcrfonrorcc olrh. {krk fi, whi.h lhh l.nnir i\
<br />i\su.d (S& 11097. Civ. C ).
<br />L.ndcis N!m:-
<br />L.ftdcis Addrcss:
<br />-
<br />d-Stllc NfIr[cL BArIoN
<br />I l[tly Ir ru frc nlivofricrlurt-.ncorrh.tull'\ir8d..hnrn \
<br />I). tr,l ion Pcn n\ A\h.no\ Norifi.arnnr Fcd.rrl Rcgrhrrnr l'lirlr,10,l,nn6)
<br />Itcq!rcd Ixncrof Norilic ri{ni
<br />I ccn,fyth, hc tadcml rcBul0rions rcBrdi+.srEsos rcnNv.lnrc mr atplic$lc ro rhh lmicr
<br />-l.cniiyllutIh.rcndlhisapfli.aln,nrfrlslllclhdlhcrtn\cinlnnnii,)ni\comcr
<br />Ixarftk,(o lPlywirh.llCirrlndCounry
<br />odir{ncc\ and Srnr. t wsEl4ingro6uiunrsrorrrrucrn,n-lndhcrc6yarrh.rilcr.fr.\cirrrivcsofrhi\Cirtnklcounlyl.ctrlcrtrFnlhc
<br />nbuvc rturnnEd nn,p.riy tur i,r$d
<br />A0Dli.nnl or ,\lrnl Sitnnlurc
<br />Prmil.r nnnr (p.inl ):Yro.r.( Vr.r
<br />*,,,v(3- 6,
<br />Set Backs
<br />Formsi Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Rool Sheathing
<br />Shear Wall
<br />Framinq /4,
<br />lnsulation/Ene rgy [- l!I I 9WtD)
<br />Drywall \J
<br />Ext./lnt. Lath
<br />lvlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certil.
<br />/ _l
<br />FINAL t0 - 161g W.W:IU
<br />Certilicate of Occupancy
<br />Notes Remarks , Etc.
<br />Brown Coat
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