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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS I)WNFJR BUII,DER DELCARATIoN
<br />I h..ehy 0llirn hdcr pcnalry .r Frjory rh,r I r r cxc'ryr lr.nr rhd Contuclom' Liccnsc tis lor rh. aollosinE rcrv,r (s...70r1 5
<br />Btr\i.css atul Pr.fcsson C'odc) Any City or Counly s'hich rcqunc\ 0 Fnnir ro mnsrrucr. rhcr. inl,)iovc. dcnrlish fr rqun iny
<br />srrudulc. fin to ils ksuancc. also rcquircs rnc amlicanl ior such !'cn.ir t lilc a sigtud {,rcnf,nr lhar hcorshe is liccnsd prnnnnr
<br />k, rhc F,vi\ions ofrhL Conkr.roi s Liccnscd hw (Choprfi 9. CommNirg wirh Seclion 701)0 of Divhbn:l oi rhc BusirE$ nnn
<br />Pofc$ions Codcl or Ihar h. or shc hcxenur lhcrclromrnd lhc b.st turhc allc!.dcrcnDrion Anrviohlb.olSslionT0.ll5hrlny
<br />lprlica tu u pcmir subtds rhc applicam roncivilp.nnhyofnor mr.rhnn firc hundrcd dollnr 15500).
<br />El. x .wtrr or nr l)n'lfn y, or my cmployecs $irh qr8c\ rs lhct solc conrpcnsal ion- will do Ilr wnk md lhc ntrturc i\ nrr
<br />i c,rtcd oroficrcdfors.lc(Sa7()44.Bu\incs\odP.ofcsrhnsCorlcTh.G)hkr.ttrsLi.cn*tjqdoc(notipplyr{,oosmr{,i
<br />rhctslrny rho bdildror nrl,oEs rtrE$.. ffil wh) dtB (kh trltt hn$cll.r her{ll.r rhmugi ii\ orhcr.wi.mrloycci
<br />n'ovided r hi snch nnrrckrxn( rrc n.r i .ndd or off.rd f.r slc. ll tx)s$q. rhc hurllmg .r i,ryewm.r is sH qirhin nm rrr
<br />ofconrrlctio.. rhcO$ncr Buikld *illlrvc rh. h cnofrtuvihgrhnr hcorsh.did tror blild or inu.vc lhe pmFny f.r rlr fufl.$ ot
<br />_1, asoNncrol'rhepmpeny. rn crclusnrly c.funcring wirh lic.n\cd contachu ro .otr(rud Itr pr.rar (Scc 7(144. Bu.in.*
<br />Md ftlltsshn Codc ThcConkaclolsLiccnscLasdocstrortpplylox osncrofp(,Ic ywho huildsor irnP.ovcs rhcrcoD.
<br />and who o racrs for sxch Fm.j..r\ wirh i Conr..rods) liccnsdd |)ursurtrl rolhcConrDcrois t-iccn* tjw)
<br />I rmcrcnDr utr,l.r Sccu.n . B &
<br />*" '{"/rr]r(
<br />D[grIaAIllN
<br />I hcr.by rfilrn:xnd.r pcnrlryoipcrj,otrcoilhc n l.lnr8 dc.hmrions:
<br />I ha\t iJn *ill tuinrrin rCcnilic.rcofCo.$nr roSclf.lnsurcf.r wortcr' c.6pcnrdn,n. d\ tiovidcd iorbyS(lio.3'7(x)ofrhc
<br />lrhor Ordc, f{tr lhc p$formrne of rhc wor* for $hich rhc tnmir t hsucd.
<br />Iharcand*'illmni airworkcracompcnsrrioninru.ai.c.asrcqundbysc.rn lTm ol thc L$or Codc. lor rhc r.rianun.c of
<br />lhc *orr r{tr*hicnnrnNnnn is nscn My eorkcr' ompcnern,n in\trrx..c.rnicr and Flicy numt'ct arc:
<br />3r ."nlry ,r,, i. ,r,. p",r".n,,ncc or rhc No.k n, which rhis Nrnrir isi\srcd lsh,llnor ctrlPl()ldnypcron i.rny mrnNr
<br />$ rs lo bcorE suhFct Io rhc *orkcr(conrctrnii{nr h*\ orCslilirrnix. r d,gft rh il lshould ticconE sh]cd t rhc
<br />worker c.nlPcnsltionImvisions.lSccrn :l7U)ofthc Ijhtr Cdic.lshtll. ionhsirhconldy!irhrhoe!R,vni( \
<br />WARNINC lJarlurc lo scuE wnlcn conrp.nidn,n c.!crs!c i\ unlnqlirl. rtrd shnll \rhjccr !n.'nploFr b rininrl tfrrrhics Md
<br />.n'l 11tr.\ rf 1,, .n. hrn,lRl rh,tr^x ,lo lr\ l\ll)t).lxN)r, r ' rnl con]Pcn\rrnin. danr!.' rt tr.ridt\l inr r[c
<br />s..ri,r.rl)76 ol rhc l rlxtr (in[. i'nfl c( xt ft nry \ lc{\
<br />u*. 'Llrtlr(A|,Plicxnr: K.'
<br />I]ECIABAUAN
<br />I hcEby dfiirm trnd.i r..rlrt ot t rrury lhal I !m li@.sn undcr Imrhion ot Chap'c. 9 (.om'fttui.e wnh Scction 70OO) ol Dilhioo :l
<br />of rhe Busimss and Pnfcsrions Cdd., aJld !y lic.ns is in lull lor.c.nd.fIccl
<br />CAXSItrIJSTNIENDTNG.AIiENCI
<br />I hcr.by rllirnundcr lr rlly ol pcrjur! rhd rh.rc is r co.{rudi,n Lndifs rBctry lor rhc pstmunrc of rh. wuA lor lhich r[is Frnir i\
<br />i.su.d (Sc..30i)r. Civ C )
<br />APPI II:AN-TDF(]I ARATI(IN
<br />I rra+, Minn undcr Fnrlry oi rcrjury onc ol rhc lnlbwin8 dcclxrarions
<br />D.mriri. PLnnir( Ashc$os Norin.tlIior Ftdcr.l RcEulrrionsIIirlc.lo- l,rn6)
<br />R.qui'rd !rnorol Norili.dhi
<br />I ccnilyrhodhclcdcrulrcsulalions rcsrrdins oshesi.! rc'noval rr. ior nppli.ablc lo iht pojccr.
<br />qlt.*'tr,t,, t l,*,-r,t'i\ apnti.dbn dld srnlc rh.r rhc rlrJun{nnM ioD h co'rccr I aBrc t, .o'ryly wnh 0ll Cily a Counry
<br />ordinrnes rnd Srarc bws rclar in8 ti huildir8 .on(ru.rbn. u hcrcbrrulhtrizercpr.scnrrriv.\.frhisCiryindCounryrocnrcroponrlt
<br />ltl,vc nEfliord |trolrny ntr ir\Faln,n
<br />ADplic!rl or Arcnl SiE.rltrrc fB
<br />e"-ir* ."." r p.i"r 1, )(- Sl€vq4 3,,.-"
<br />(, /tt ft(
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Rool Sheathinq
<br />Shear Wall I
<br />Framinq 6-22"tV ,44t4,
<br />lnsu lation/Eneroy
<br />Prvrv4{'//'-\)Xlnl] L-atn bzZ-tv
<br />Brown Coat
<br />Itrlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />t
<br />FINAL t\q,\\s\Certificate of Occupancy
<br />Notes, Remarks, Etc.
<br />.,'.,,". x-.t
<br />Lilr nsc C lass:-Li.cnxc Numh.r:
<br />-
<br />D.re' Contaclor
<br />-
<br />t nrLls AddF(
<br />-
<br />UFER Ground
<br />Subf loor/Vent/lnsulation
<br />ywltl
<br />Arxh\\\\
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