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BUILDING- INSPECTOR RECORD
<br />or!NER lrull,t)t:R t)Et,cARA'uoN
<br />I hcrchy rJlirm u cr frMlly r, lcqury rhrr I rn cxcifl ln,n rhc Coikr.ttri Li.cisc l){ fd lhc hlkisnr3 rcrs,n rscc?l).11.
<br />A!\i',c\\ rtrd lto[$i{)n C.dc): Any Ciry or Counry whi.l] rcquncs x |tnnir t' .ofnnrr. alrn. i'np(,v.. Jc r,lnh , r '.Ft rt
<br />slfl.rurc, pri.rro irs ir\urtr.c. ako rcqut \ rh. rppli.Mr Lr\trch lrnnf h i]ta si!trcd qdcnrtrl th.t hco, shc h lic.ns(t
<br />lo Ihc pFvniors of rnc Co r.clols Liccnrd tiw (Chaprcr 9, Conrmcrcin8 wilh Scction ?(X)0 ot Divnion.l ofrhc Bu\incs !i,
<br />PnncrsionsCodcrorriar hcorshc hcrempr lhcrcfronrand rhc b.\n fo, rh. rllescd c\cnv,rion Aiy viollrionors(rioi 70:ll5 ht rni
<br />rpnli.dr fu r Il(nnir srhjrcrs rhc +Ilicanr b r .ivil ncnohy of nor mm rhm filr hundrd dollars ($501))
<br />-1.
<br />0s ow.cr ot rhc fotcny. or my cnr,'hrccs anh *agc\ rs rhcn $lc con]Pcflstrion. s ill do drc wolk and llE n tudtr is ior
<br />irncMrn or olftrcd fitr {lc (SLr 7O4{, Bu\ircs\ and }'rolcs\ion\ Cnlc 'l tc c()nrr ktr \ Liccn$ ltrwdft3Nr Dmly to ostrcrof
<br />rhc rmncny sho h{ilds.r irymrcr rhcE n. ad *ho des \Eh wo* him\clfor hcrelfo! rhmu8h ht or h.r osncmfloyees,
<br />provdcd rhrr such nnfmlanr.R m to imcnd.{ or ofi.ftn for {k Ii h$.vcr. rhc hoiklin8 or imrn,wnrn( is $U wirhD om ,!r
<br />.fcon{,lcrbn, rh.1)*n* Brikhr sillMh rlE hrrdcn otpoving rhartf,orihc dil ft, hui or inrno!. rh. potffy tnr rh. !)urf.$ of
<br />I- r\ormrofrhc porcny. amcr.tusitrlyconrrrcrirg *ilh liccnscncodrr.tn\ro.oDnrud rhc pmjccr (Sd. ?O14. Bu\itus
<br />x.d ftnision Codc: lhcConraclofsLiccNLawde\mrrrrlyro0nowncroapror,.ny*hobuildsorinrprovccihcrcon.
<br />{n'l who otrtrcrr for such prcJc.r wirh n Conra.b(\ r li.cned pucu{nr ro rh. Cotrt!.rois t,iccflr tj$)
<br />""1{i
<br />I hc!.hy xlliinuodcr f.-nrlry of!.rj!ry.rc oirhc foln,sir8 dccla
<br />I hivc md will'minlrin.c.nii.rrcofconscfl l(,sclal'Nurd fitr eorkln ..mpcnsliotr. as [ovidcdforbySNtion]7(x)ofthc
<br />Lrbor Coilc. fo. ibc p.rforddncc ofrh. $ft tu shich rhe p.flnir n i\sucd.
<br />.<l hrlr and s r ll mlhrdn s n*cr' c.mn( nsJr '.n r tr\udn.r, ns rcquircd by S(r ion 17u) of lhc Lah.r Codc- a.r lh. pcrronm cor
<br />lhc work i.r which rhi\ pcr.ir issud My sorkcn coilpcn\.rion insurancc clricr lFd policy numbcr m
<br />4r e?a( 4osv4 6x 3
<br />I( iltrhrrinrtu rlnnunccofrhc{ortfr\rhi.hrhi\|Innlisn\!rd,Ishrllnorcnrll(iyrnyr{_^onrnrtryDmncr
<br />$ {\k)h..onE q,hJNr n,rhc $o cr(co.rticnsdionlrq\ofcrlnoaria.rnda8rftrltuifl\lx'uldbc.o'msuhicrk,rh.
<br />$oi(cs.onrncn$ri(inprovisionsolSccri lT()l]otrh.l.{txtr(frlc- l \hrll. ionh$irhsndt eirhiho$ pmu\n r
<br />WARNIN(; Frilu'a r) \ccurc sorko(.rnrFi\rriinr ovrr ac i\ udhslnl. rd rlrall s'hjccr di cnDloycr n,.i'ni',rl rnrlric\ tr,|
<br />ovil inrcs ulr ti rflc l[drcd thousrtrd i]oll{rs (S100.(x)(l irion ro rhc (o( oi comncNxrion- dJnuEcs rs frovidcd lor rh.
<br />(-nl. i' crc( xn inai,Ev l
<br />/(
<br />I tuchy.inm u crr.mllyolDcrn|rylhnl Iam lienKl undcr ffovitionofCh!p'c.s(.o'niri.itrp wirhs(rbtr 7000 ) ol Divhion .1
<br />of rhc ausiftss.nd PnfcssionsCodc. ad nry liccnr n in tulllorcc 0d cfial
<br />Zq q6C tt1
<br />{
<br />I hcEhy rmrn undc. p.mlryol pcrjury rh{ thcre h a conno.tir tndirs.senc! irtr rhc p.rronn,n.c orrh. work hr which thn Firnir n
<br />irsu.il (S.c. :1097. Civ C )
<br />AT]I.,ICANIIIiI:LIXAIIO!
<br />I hcdyfllfunu er pcnnlly oIrcrjury oDc.flhc followins decliralioDs
<br />Dcndition Pc.nnsA\h$os Norificalio l,cdcnl Rcruhriotrs (Tirlc40. P{n6)
<br />Rcqutcd lrn$ of Ntnif dDn
<br />Ltr,ln,xDr.\ rfti Srrrc I rs\ rrli l,ldin!con{tuchotr.x'xlh.r.htrrrln{iturct,rc(ctrr.lrrc(ofrhisCit,andCounrr_t,c.rquI.nrh.
<br />rh.vc nrntioncd nrotcny lnr
<br />SITE-WORK DATE ID/SIG.COMMENTS
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Rool Sheathing /'7) (g /,q.4(is,
<br />Shear Wall I
<br />Framing
<br />lnsulationi Eneroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil
<br />I
<br />lOt
<br />Certificate ol Occupancy I -l u
<br />Ngtes, Remarks, Etc
<br />"7
<br />o
<br />v|rf
<br />n ra /-P14<-e
<br />,,"," b/t!-/
<br />Sel Backs
<br />UFER Ground
<br />FINAL
<br />L
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<br />Lcnd.i. Addrc$:
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<br />lccrrilylhrl lhc IcdcrrlrcEUhliof\ rcrffdirg.sh.( rrcnn,vilar.norrttlicxhlct)rhi\pi(+.r
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