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SITE-WORK DATE ID/SIG.COMMENTS
<br />Set Backs ---1 /-^;-)
<br />Forms/Steel/Holdowns '26 /3,cea Yr"'
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Venti lnsulation
<br />Roof Sheathino 81 7t a4n
<br />Shear Wall tg UA/r(?)x
<br />Framino Ito >rr 24l,,
<br />lnsulation/Enerqy 7 t4 -.u*rd,)
<br />Dryrqall q/201"{ -'Exjlnt. Lath q t'7 I g ..1-,(24{r I
<br />-Eiown Coat 161-r-tl t 'qt(ad
<br />l\4aso n ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report \
<br />Flood Zone Certil.
<br />iirn*dFINALl1,l9t (*'4)
<br />Certificate of Occu anc
<br />Notes, Remarks, Etc.7
<br />BUILDING- INSPECTOR RECORD
<br />OWNER BTIILDER DELCARATION
<br />I hcrcby rlfinn unds rnshy {'l pcrjury rhd I n'n cxc rtr lioh rh. Cont,.rois Liccnsc ljs for rhe folbwinS rc,q,n (sN7{):11.5
<br />Bu\incs and Pnrc$nrn Codd) Any ciry .r Coutrry whi.h icqntrc( r Fanrir lo con{o.r, rlrd. imnrorc. {rcmlirh ot rcpat ony
<br />{tu.rrrc. rrior i, \ ksurtrcc, aho rcquncsrhc alplicrtrr ix such p(rnir ro lilc r siamd {0rcm ihrr hcor shc h li.cisd PtrNIntrl
<br />ro rhc [ovi\i,,n\ olrtr Cont].r.i\ Lrcnsrd hw (Chiprd 9. CoNnencin8 *irh Scdn TfiX).1Oivision I of rhc aurincss rnd
<br />P$fcsrion\Codc)orrh.r hcorstu ncrc.Br rh.rclromand rhctusi\ for rhcnllcBcdcxcmPtion. Anlviollrioo.fSc.tirn70ll.5bylny
<br />otplicanr hr! ncnnir suhje.(rhc smh.a l. acivilFnnhyofnol nmrcrhrn li$ hlndrcd d.lla* (s50o).
<br />-l-
<br />a\ owicr trrrhd pn,frdt, or rycmploler *irh w.ses a( Ihcir slc con{rngnon. willdo trt wtrk md rhc nn*h i\ tut
<br />inr.ndcd orofi.r.dforsolc(Sa704,1.Bu\incsandftofc$ion\CftlcThcG,ntnctor'sLic.nrLasdo.snorrmlyr.inoPnctof
<br />rhc In)p.ny *ho huildr or in$ovs rh.Krl xlrhod.cs\uch{r)!thimscllorltrslforrhnughhisoriero*ncmpl.y..s,
<br />prcvntd lhlr $ch in{x'w.rnh r. nor ii cnddl ., ollcnl lnr eL. li h.wcv.( rlI htikliiS or in9ft)wmnr i\ s)kl Nirhin nc ,tr
<br />ur.o prcri).. rtr osrr Buillcr will hore rhc t{rdcn ot Irevins thd hc or \hc dil n.r buiH or i.{mvc rhc pmFly Io. lhc luqnc ol
<br />f!-.J,,..*,", nrrr," lna.nv. !.rcx.lu\ivclyc. rrcrinssirhliccn\cd.ontd.u{h.on!rucrlhcPn)r..rlsc. ?(}1,r. gu\inc$
<br />and lt{'lc$irr Codc: 'l hc Conhctr'\ l-iccnr Ir* doc\ nor rpllv b {n ns ncr of pn,I. yqh. huild(ot tnPrnc\rhcrcoi.
<br />rntl *ho . rLr.rslorsuchporccr silh!Contrrcttrl\)liccn\.d pururtrr rorhcConrr..rois l-icctrsc Us)
<br />dr *" *.,,rr *,0. s".,
<br />o," z /rr/ "arg o"V ?E-Ig & ?+14A./ . W(IRKFR{ C(ITTPLNSAT!(,N
<br />DECIAf,AIION
<br />I hcrchy alfiirn undcr pcnllryotperuryoe ofrhc followine dftldrln F
<br />-l
<br />hrlc $d vill minloin o Ccn ificdr. of Con*nr b S.ll"l nsurc nI workcn .ohptnsd bn. * [ovided ior by S(rion :]70O .f rh.
<br />tjb.r Cod.. fi,lhc p.ifonErcc., rh. *.* f(, whi.h rh. Fm is issuci.
<br />-l
<br />hrlc and *iltnri rin porkcH .omrcnsolion insurcncc, as rcqoird hys..Lotr 37u)ollhc Lll,or Codc, rorlhcrc otmonccoi
<br />rh. !o.k ft, whthrhi\ p.rnir is issu.n. Myworkc^ comt nsalion inror,nLr .xni$ ard ,inicy nunther m:
<br />Poli.yNunrl{r-
<br />r.niltrhrr drlrNrlornnnc..Irhc*orklorrhichrhi\pcnnili\n\d.,1.Ishilln,lcntnryrnypc^otri'rdtrynr rn.t
<br />so $lo hesnE subid lo rhc workci\ co,rydsdrnJn hws orcalirarni0. and alrm rhm irl should tt.om sutjd b rri
<br />rorkc!{ onnensarion pmvi\n,ns of Scdbn ll00 ol rhc bbor C(lc. I lhill. lirnhuirh .o llly wnh rhos Pmvi\n,ns
<br />\YARNIN(;: Frilur. b murc sorkcis conlPcn\arion c.vcrugc i! lnlswful, trnd shrll subrccl io cmPloitr r..rnltnil |aMllic\ lnd
<br />cilil finrs up k' oN huftlrcd rlnusand dollm ($lOll.UI)). irr addiln,n i(, rhc.o( ol conrpenslrioi. datugts a\ Piovidcd l'or th.
<br />Sccrion 3076airhd bbir Culc. mlcrcsl rnd llrrmy s lccs
<br />b/L]aot$ N.PE-rER ?tl4,t1urxNl:ulllNMlq!]a
<br />DEC| At{\]r()N
<br />I hcrhy alfirnr xndfi p.trrliy of pcrjur,lnar I a'n licenkn under pmvi\n,n orch,fls 9 (com.Ercins wirh sc.rion 7m0r oll)ivnion 3
<br />oI rhc BusiDc$and Pn,ie$trnlCodc, md nry liccnsc is $ tlll lore lnd cfliLr
<br />-i.c \. Ntrmbcr
<br />-
<br />LANETXJ]qI9NIINDUC-dCrNI}'
<br />I hcrchy alltnrrid.r F lrtorlcrjlryrhdlhcrcntrc.trnrudi(rbndiicr!.ncyrdrhcl)rrr.,nmmcolrh.*orkrorwhichrhisPcn.irh
<br />nsucd (Scc. :l(I)?. Civ. C )
<br />btrdcr's N.,ncr
<br />-AELTCANLDISAAAIIAN
<br />I hsd,y airm und.r p.i,lry !l rcrlury onc ol lhc folloyin8 d(l,rario.i:
<br />Dcnolirion Pcrnik Ashc$os Norificntion Fcdcr.l RcEul!'ionr (_rnt.1()- Pnn6)
<br />Rcquir.d lrn.r or Norifi calion
<br />l.cnnyrh[ rhclc(lcr{lrcgul]rions rc8Iding"sb.(oic n,!r1tu. for rp|]li.xhlc hrhi\ pqcrr
<br />.cnil.r rhrr l hrvc r.!J rhi\ dtplr.rriotrrftl (ircih rh.rtrnc irlnrn nD n comcr I rlrccr).dn]!ly*ilhrllCiryrfl (otnrt
<br />o ininccs a Slorc l-aws rcl in8 b firiklin! .on{tucrn[ atrd h.t hv runrrizc tnrc\cnbri!.\,]frh'\ any rnd Counryro cnrcr llloi rhc
<br />rb.vo mnrnnrd F)Nny nlr iNt)crrtr{r I-?l^^
<br />ir trlor \FtnlSirnEltr€
<br />,eenanr(prrn,): Pff PJ+4f4
<br />X al|zoLB
<br />(/ ,t
<br />'rt r{fi
<br />''7
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