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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE COMMENTS OWNER BUILI}DR DFJt,CARAT1ON
<br />I hcr.hy mrm !nd.r p.n , .r p.tury rh.r I dn cxcm rn,m rhc conk b6'Li.cnsc bw tulhc nnk,wins rdn{n (Se.7o.rl t
<br />Bu\inc$ r l Pn,f.*i.n Cod.): Any Ciry or Coutrry whrh rrlluircs ! tErmir to con{rucl .hcr. inrpfuvc. d..r,lish or rcp8t ,try
<br />iru.ruo. prior k ir\ ,$u,n.c,.ho rcquircs rhc +rli.i r n, su.h tEirnit Io lilca sirncd (llcrcnl rhur lEor lh. is liccn{d N$uanr
<br />b rhc F,vnnn$ ol the Conr6crois l-icc.*d tiq (Chlprcr 9- ConhcicinS wirh S.cliotr 7uD oi Divnion :l olrhc Busincs and
<br />Pmfcsnnx Codc ) or rhnt hcorsh. iscxcmpl rhcrcfnmnnd rhcbisn for lhc lllcscd eicmprnrn Any vn,hri.nofS{rirn703l5 by.ny
<br />lprlicanr lhra pcnnitrubjNls lhc lppli.anrioacivilpcnrlryornorfrnerhanfirchundrcddollirc($500)
<br />I. N o{trd of lh. l,olEdy. or my employccs with wu8$ rs rhcn qre c\impcnsri,,r, lill do rhc w.lk tuil ttr ddN i5 trur
<br />irkded or orcrcn lor silc (Ss.7(x4. Busircss rnd ltr'c\sions Gdc: thc (-onttror'i Liccn$ tiw dms nol 0rDly ro u o*ner of
<br />r hc ln,l.dy whl huilds o' in{,rov.s lhcmr dwhodftssu.hw.rkhirn\.lforhcrscllo,thnugnhiso.hcro*ne'npl.yccs.
<br />providcd rhlt ruch imtmvcm s N nor i cndql or ofiircd li,r \xlc ll ho*c!u. rhc h^ildin8 or inyn)v.m is s,ld within nnc JEr
<br />or co pltrion. th. owncr auildd w l h.vc rtE budcn ol ,'nvirS rlrr tu or shc did mr build .r i,un.vc rh. f,mp.dy ror lhc |)Ur[nr of
<br />-r.!sowncrofrh.lmpeny.amcrclusirlyconr,adinswirhli..n\cdcontrcro^t,connrucrrrEtojccr(sc.7oil4.Bu{ncsanl Asf6ssnCod.'IhcConrmcror'sLicctrseL!{dcsnora0tlyroanosncrotnropcnywhohuild\.rnhpmrcsrhcrcon.
<br />ad Nho co.hck ror su.h ptuic.r qirh r co.rn brl s) lk{r*d puNan o rhc conrrroa s Ltcn{ ue)
<br />lrNd.nfl und.rsccrion .a &PC lnrrlri\rcrwr
<br />OPner:
<br />trl)Btr[85:caufl:ll IoN
<br />D[(;L$4.U0!
<br />I hcrchy amnnutrdcr pcnrliyolpcrjuryorc ofrhc lollowinB d(lamrions:
<br />lh.!cntrd w,llnuirrotu0 Ccrrilicalc of Con$nt ro Scli-lnsurc r'or sorkcn compctrsdnii.as previdcdrorbySalion:lT0Oorrhc
<br />tih.r abd..lar rhc NrlnnDmc ofrhcwork for shich rhcpcirnf is ksucd
<br />_lharc lnd willfluint.in $o,kcr' conllen\Drb! nNurrNc. Ds requn d byseriotr lTtDoarhc tilxtr C((lc.lor lnc pcrturnDn.cor
<br />lhc work forwhichthis pcrflir is issucn M,worlcE conllrcnsari{nr insurakc.mifi and rolicy nu{rhci ne:
<br />Policy Nu'nbcr:-ErpiB:
<br />I.cniry rhrr in
<br />'he
<br />F.rrormn.c or rh. work lor whih rhN Fnnir i\ tsucd. I \h!ll nol cmploy trny ptr{,n h ant nri.ncr
<br />s s to heom subj.{l lo I hc sorkcn' compcnsa' bn hw\ ol Calirbrnin. Md 4m th,! il I should bc.onE $h/cd ro
<br />'lEworkcrl conrpcnsrion provnions olSccrion:17(x)dtrhc litnr Cdd..l\hxll. rbnhwirh conrdy with r hoc ,'mvirionr
<br />WARNIN(; Frilurc (, surc w.rkcn compctrsrtion covcrr8. h unlawtul. and shall subtcr m cnplortr b rirninrl lEtrlhis lnd
<br />xx)). rtr rd(lii,itr t) rho .on ol .on\f, \rrr!r. dr !.! pnxiJ.J rnr r[r
<br />,lQ-a11 t
<br />DECI.AAAUON
<br />uM.r rmvision ofChaprcr 9 (c.mDfting wirh scrion ?000) ofDivhion 3I hrrcht rllimu or t^-.nrlryol pcrjuryrhrr I t I
<br />of rhc Busim$ md PrcfcsionsCodc. a,i nryliccn* i\ ir fulllnru arxl xffc.r
<br />,l t(
<br />I hcrcbyilllrmtrndcr Ntrdtyofncrjuryrhit
<br />is\ucd (Sc.. 109?.C1v C ).
<br />rucliu lcn.linga8cncy f.r rh P..lotn .c olth. work lnr([ichrlrit pcnnir's
<br />AIILTI;ANLDEII.AAAIION
<br />I h.afiy a,linn u c!,Enally olFrjury.nc orrhc rolk,*ine dNhnrionsl
<br />Dcml ion Pcrmih-Asbcsros Norificarion Fcdcral Rc8ulnrion\ (Tirlt J0. Pd6)
<br />-Rcquircd
<br />t rrcrof florificarion
<br />rctrk^nlirc ror.ptlicnbk n) this pn)F(r
<br />rhtr! nlnnnrrioi n.orc.i I r8ret,..n{)ly$irh lL( ir!nnd (,{ r"ry nl (,)utrry ro cn(cr qrotr rlr]rrchyxurhri2. rctrc{nhrivc\ ol rhis (:i
<br />l( 7--
<br />tfu/tx
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/Vent/l nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing z//n 4 X'q^
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlason rY
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />I
<br />FINAL fl/ib//a /dd<Al
<br />Certiticate of Occupancy / ' L/ / \\ 1 U
<br />Notes, Remarks, Etc
<br />ID/SIG.
<br />a3040tR
<br />kndci\ cddrs{
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