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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER AUILDER DELCARATION
<br />I hcrcby allirn utucr rcnrlly {)i p.riury rlrd I am cxcm|rr tiom rhc Conrrackns Liccnsc Law iot l[c n,lbwid! rcrsn (Se.70.]1 5
<br />Bulncs ud I'ro,ession Codc): Aiy City or Counry $hich tcqutc\ r Fnnir !, .onsln'ct. allct, imfr.v.. dcDplhh .r ruIrn anv
<br />(rucrurc, d{trnr ir\ nsum.c. ako rcquncslhc rrplicanl lor such p.nnir b filc a sisncd sr cmc rh,r h.or shc is li.cnscd prhua r
<br />l. lhc Frvkions ol lhc Conlracitr \ I-ic.i\ti] hw (Chlpl$ 9. Commcnci'rg sirh Sc.rion 7(x)O oi Divisin .l .l lh. Brli'r.s rnrl
<br />Pftrt$i.n\Codc)orlhrrhc.rshciscrc.r lhscliomud lhc hasis l{trrhc rllcgcdcrcnDlion Anyvi(,hrnr.rScclionTr).ll5hy.ny
<br />applicrdt fuaFnnirsubjc.rslhc inIli.!nrb rcivilpcdrlry.ftror xtrc rhan liv. hundr.d dollds 15500).
<br />-1.
<br />!\ o\rNr ol rhc !n,t rty. or nry cnrfhyccs wirh wa-qe\ rs tlcir dc .omNflsrr iqr- $ill d. rlt work ,rYl thc nruru( n nn
<br />i, cidrd or .flar.d for uh 15€.7(!.1- Busine\r Md Protcslnnrs C.dc l hc Conrrrcttr s I j.ctr* tis dos nor aPIl, b tu owNr oI
<br />rhc Dol,cny who huills.r inrpRr.s rlf,rcon, rftl rvho do$ such sor[ hi'ns.lf.r hcr{lfor rhmu8h his or hcr owi cmPloycc\.
<br />lj' ovidcd rhnr ru.h imnrcv.mnN rc nor i'n.ndL\l or .lLrcd lor {l: ll. howcvcr. rhc buiklr* .r imliDrcnrnt i\ $U wnhi'r nrc rr
<br />ol.o.Dlcrion.rh.OwnrBuildcr*illhrvcrhchdfttrnollR)virrgr)rrhcorshedidnorbuildornPn,vcIhclr,IEnyf{nrhtulr{ol
<br />l, r\ owncr of rhc tml)cny. amcrciusivelycontrrrir! wirI li.cn\cd coDtrr.lrtrs i) con{o.r rhc ,)l.jcd lsct 7(l:,4. BurDcss
<br />aDd lt Lsh|CorL:'lhcCotrrnctr'\Li.ctrscL.wdocslorrntlyi)rtrowrcrotni(,PcnyshobrildrornnprovcslhcrcoD.
<br />md Blb .o.lr$lor rurh p'riccr!sirh nC. tr.lo(s) lic.nscd Dursurnr r)rhcCoDhi.rofs l-iccn\.I-rw)
<br />I rNcrcnr|n ! cr Sc.rn,
<br />]IANKIBS].COIIIENI/UIAN
<br />DIiILA.B{IIQN
<br />I hcrcbyain njldcr p.mlry oiperjuryond olrhc n)lkNirS Jccldrari(!rs
<br />I luv. dd will nnidsin !Ccniliur..fC.rs.nrro ScltrlNurc lorwolkcrs on]P..:ddr. rs provnbd lor bySccriotr l7O0oilhc
<br />lihtr Cod.. tur tl[ pcrloanitre of lh. *ork n whi.h lhc p.irnir t isa'cd.
<br />Ihdrtrtrdsillnri iinwoikcrr.o rt)cnsarni iNur1n.c. is EAUi'ldhtScoi(,n1700oirhclrho.Cr .. t{ rhc Pcnnrrmncc ol
<br />rhc work tirr Bhich thispcflnil i\ issucd. Myworkcs .o.Uctrsrlio tr in{rrn(.r"cr iM policy nufier&
<br />Na*ro"ral (ns Co Im<-
<br />.9wL1la Ol-ol-z.otn
<br />I..nityrl,ir ltr rhc rurfo"mNc.{ lhc sork lir $hich rIi\ tlnnir N i:{ucd.Isl[llnor.nlPltitn yncnon innnr nunrcr
<br />sr a\ io ir.oif, suhlc.r tu rhc *or[.A'con'pcnsrr(n lrss (fCJlrlornii. xnrlx!'.. rhrr it I shoukl h..oru {'hiccr t, rltc
<br />so,kdJ.otrrfcfsrrionnovirions.fSLrrnri:l?00olrhcLdxfCodc.ldnll.l(trrlrNir[.oNp]y!virhrh.{P(,ri\( \
<br />nr rrc hutrdci rhou\rnd d.llr\ (Sl00.l,tD). irr idtlirilr h rhc..j ot .otrnLrJrri(tl d nr!.\ r fr.vi(l.d,n. rhc
<br />Sccrtrnr 1076.lrln l-rhnC..L. idcrc{ dd ktrrcy ( lacs
<br />-b-zs'rt
<br />I hcrchy uffi.nr hdd pcnrxyotpcriury lhrr I rm li.ctrwt undcr pmvsion ol Chatr.r 9 (.onnncrirr! wirh Sccrbn ?uD) orr)ivision l
<br />ol thc Businc$rnd hor.\snrsCodc, flt nry licctrsc h i'r rullr.r.c atrd cllt.l
<br />c-?<q tZLa
<br />b -2k-\{(
<br />(I)NS tRUC-l.t()N LtjNDtN( : A(;UNCy
<br />i\\ucd (Scc 1097.Civ C)
<br />tr,,t.1'. \,,,T _
<br />Larncr'' Addre.
<br />^IILIL:ANIDLCI}X^IrA!I l.crcby dlnm 0 *lcr Nnalr! olpcrjury orc orrhc ft,lbwi'i8 dc.l&dlions
<br />Dcnmliriotr Pcrnrir A\b.{os Nolilic.lion ltdcril Rcsuldnnr (Tirlc,10. Pfi6)
<br />-Rcqutcd
<br />lr(.r of Norifl(iotr
<br />I.cdilyrhil thc Ldcr!lrcgnl' nrs mBnrdirg istEslos rcrDrolrrc n.r nmlic.blc 10 rhis tnl.cr.
<br />I ccnify rh,l I h{vc rc rhiaptli.drnnr mn si,lcrlullhc atx,ve inblnrnoD hconcd Ilsdr..o'np ly wirh rllCiryrrd Counry
<br />o'Jinxn.c\ n Srrrc Lnssrcldingti huiLli'rg.oinru.noi
<br />Lb?#,l/
<br />r.trcrcdrrivcs oirhn Ciry
<br />rhon nEnli,)ncJ px,I[nt lar (
<br />a 6V\
<br />(-(/
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />SubllooriVent/l nsulation l
<br />Rool Sheathing 7/1//d t,',N./f)
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Itilasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL 7-l?-/9 Jy't tat {vr)
<br />Certif icate of Occupancy
<br />Notes, Remarks, Etc
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