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BUILDING. INSPECTOR RECOHD
<br />SITE.WORK DATE ID/SIG.01{NER BUTLDER DELCARATX)N
<br />! hcrcby rlfirnr lndcr pcnalry or pcrjury rnd , m crcmfl tinn rhc Conta.tH Licenc Lo* fitr rhc rollowin8 rqson (Scc ?0ll 5
<br />Buiiic* n.d Pr.rcsion Codd: Any Cily or c(,onry shkh rcquncs a pctnil t' c.nitud. .lt.r. improrc. denxni\'& or repri 0nv
<br />{fl.rurc. Drio! ro irs issulncc- also rcqutcs the 4Dli.nnl lorsuch Frmil lo lild I siSn d $alcmnl rh0r heo, shc is liccnki punuonl
<br />In the porisions of rh. Coftelois LicenEd tlw (Chopr.r 9 Connrncing {irh S€ctioo 70ff) of Division I otrhc Aunncss ond
<br />Pidacrsions Cod.) or lhnl hcorshc is.xempr rhcrckonraM lhcl'asn i.r rhe allc!.d .rcnpti.n. Anyviolllionorsc.ri,n?0ll.5l'y'0nv
<br />ap,rlicdnrlortrFinilsubrrcl\lhd,pnlica.lroacivilpcn0hyotnormorerhrnfiv.hutrdcddollln($5fi0
<br />l. 0s .wncr of Ihc llrolEny- or hy cnlfk,yccl *irl w4cs !s rhcn st conrP.ns,rnrn. sill do thc work ad rtE dmn'r t n.r
<br />inrcn&{ or olTeR'd lor \ald (sa.7o44. Busincss and h)fcssions C{nl. Thc Coitrctols l.tc.t l-nw docs nol rPplvlo 6osncr.r
<br />rhcpml(ny st(, builds o. in{'oEs rhcron. d qho d(r $rh mA himsellor hcF.lror rhmuSh his or hcr o{n cmlloyccs.
<br />Dovadcdlhrr suLh inrfmrm*.k rrc nn intc cd oroficE'd lot ulc lf- h.*evcr rli t iklina or iqroEnEnr ir k,ld *ihin onc vt0r
<br />of.onDhr ion. thc Ouncr Slit cr will hak rh h{nlcn of Pioving rh.l lE or sh. dil nor huild or nnpmv. rhc lFId, nn rhc po$Nc of
<br />\I/*,.. ",,r" ,,,,*"y. rm cr!rusi,cry cunrra.r,ns wnh ri.cnscd coftr.r". b connru.r rh. pmi*r (s( 7{g4. susi,Ess
<br />Fa p.r.o"n c"a. ir,i c",r,*u"i' r"c,,.c rJ*,r.is nor uprly ro an oRn.rolpopcrr, who huii<r. o i,nprorcs rhcrcon
<br />eDd who .ontich tx su.h rmjccls {irh u ConrEct,(t licd{d puruad ro lhc Contrcroas Li.cn{ trw)
<br />tl,,ion-. B. & PC lor lnt rca.on
<br />^" b[<]}AX rltl:rANllrN!!-lltJ!DXll^3rrrcii
<br />I lttu6ynii"nuidcrri.iilrtolNrluryoncolihrlnlk,$i'rg .rl$rtonr
<br />-lhovcmd,ill,tuinrdhaccnnicatcofConsctrrloSclfln\trcn,sorkd{.o
<br />Petrs bn as rmlidcd for hvSecrion lTfi)orth.
<br />Ijhr C'(te.lor th. pcrfomtu. orrhc mrk tu which rhc pcnnir t i\\ucd
<br />lhrvc rn,t sill hn air workcra comneo\dn,n inixfun.0. dr tcqunql by Sccr id 17m ol rhc Lrhor Codc. f.r rht p.tfonu,E ol
<br />rhc *ork fitr whi.h rhis !.nnil i\ issuc(l Mt workcrr .otnFtrsdri, insur cc crri.r n poltynuntcr!rc:
<br />DECIIISAIION
<br />I hcEhy olitm undcr pei,hyorpcrjuryrhar I am liensd trndcr roridon ofChaPtcr 9 (La,frntRn'8 with Sdion 70fi)) 'rDivtnr l
<br />of ih. Busnrc$and Pnrc$ioisC.d.. ud 'n! ltcnse n in rulltorcc udl cffccr
<br />CONS'IRT-IC]'I(IN !.ENDINC AGI]N(IY
<br />I h.rchl affinn trndf l.Mlry of periry rhrr rhcrc isa..nnfl.rt lcndiflr +cn.y f(t rh. t^-.rl'on. ccofrhc sork li'r ththrht Frinir n
<br /> PPI I(]AN'I DF(:t AR,{TION
<br />I[nhy{fiinnund.r pcnrlry oft,criuryonc ol rhc lollosinS dc.lrrridN:
<br />Dc n,liriur Pcnnil! Ashcio\ N.rin.ari(,n rcdcralRcAuhrii,n\ (Tirlc il0. P&6r
<br />adE{os rcnr)ril rrc or rfNi.rhlc rorhi\ ln,jccr
<br />rc infornhrior is corcd I rgrN b (mply
<br />c,u;c;
<br />R.(tun.J Ir(..f 1 Nor'li.nr.r
<br />[;r:ry,:,,'_"
<br />,v!;|#:.
<br />Set Backs
<br />Forms/Steel/Holdowns 844K Y,4rA,
<br />Erection Pads
<br />UFER Ground
<br />Subf loor/VenVl nsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framinq gn'qv Y.
<br />lnsu Iatio n/E n erg y
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />l\/asonry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />----
<br />FINAL ,11L0lR lrrrttw,tv,,i92-/
<br />Certif icate of Occu n
<br />Notes, Remarks, Etc.
<br />COMMENTS
<br />SLAB Floor
<br />T-Bar
<br />crnir,
<br />-
<br />h\ucd(Scc lO97,Ci! C )
<br />t ndcCr Nam:-
<br />xtx^. trRnrtr,( t"'ttrlrt ntr
<br />Pcmrite..nn,.lprinll:
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