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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Boof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Ener sv
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL lL/tx/tb iw
<br />Certificate ot Occu pancy
<br />Notes Rem arks, Etc.
<br />Otl'NTR AUILDIiR DT,]LCARA'I'ION
<br />I hcEhy affirnr undcr l)cnahy of rrJury rh l am cxcmpr lmm rhc a.nrNIon l-iccn\c lfl* lor Ihc follosins relvrn (5(.7031 5
<br />Ausiic\\ dd Profr\\t,i Code) Ai! Ciry o, A nry whic[ rcquilcs a pcrmir k, condtucr. drcr. ihprcvc. ddmli\h or BP r my
<br />sdclurc. frix b n\ issurnc., il$ r.quim rbc applicanr ror \xchFnnir !, filcr ntncd {arcnrnr rhm h.or shc is l,cc.scd Ntsu!trr
<br />ro rhc F,visnrnr ofrh. Conkri{, \ l-iccnscd Llw (Chrpl.r 9. Co'nn*ncing *irh Sc.rion ?(Xx) of Divi\iun:l oI rh. Businc$ and
<br />Prnic$ionsCodc)orthalhcorshctcrcmflrhcrcrio,trdrh.basislnrrhcnrlcScdcxcnUiotr.AnyviohrionotSccrion7011.5hyrtry
<br />lppli.an' lnr a ncnnir sul,jccls rhc appliqnl r. rcivillrcnrhyofnot nrrc lhu fivc hundrcddnllaF(t5ol))
<br />_l- ar owrer of rhc rroFny. (r flry cmDk,yes aith a.Bcs rs rltrn $[ .onrFnsor ion. will do rhc *ork rd the rrtrru is m
<br />int.ndcd or onarcd f.r elc lSN 7044. Brsi..s ud Pmfcsii,ns Cod. Thc Conkrcttr\ Lkctr$ tlw d..s nor npplt b an ow..r of
<br />rhc rspeny who builds or imprclcs tlErtr ad wio dc such m* hinFclr'o, hcNlf or rhou8h his orncrown.np!oy..s,
<br />pft,vidcd rhd su.h inpmvc,tunh m n i.lcnd.d or ollcet tu! qlc lt hoscki rhc hildi.g or iq,mvcmm h n d wilhin onc )M
<br />olconpldDn. rlE Owncr Auihcr will hivc rhc bdfl|n ot ttu1ina rhd tr or sh. dii fr bxib or nnpo\r thc pnrFlt lor itr puqr$ of
<br />l. rs osncr ofrlD pn,pLny. a crclNivclrcotrt,crios wirh liccnrd conrrrr.n r, .r,0nflcr rhc prl.cr lScc 71r{4. Bu\i'-_tr
<br />and l,lorassirn Codc: rhc C.nlrdor's Li.ctrsc l rw docs tror r,'tly ro u ow.q o r Fopcny $ho huilds or imtolcs lncrco..
<br />dnd *lb conrEck itr \rch pn,jccrr wnh u G,nrDc'ons) lien{d pu.\ua h ihc Comrr.ror'{ Liccnsc ttrw)
<br />-l
<br />ameicmpr und( Sccr
<br />EI}BtrE8S:I;!}!IIjNIAION
<br />PECLASAIIO!
<br />I h.6by trltli'n xndcr FdahyofFrjury otu.arhc folkrsirr d(lmrio.\:
<br />Ihalcuxlwill@inrrinaCcdific,rcofCon{nrroSclfln\lrcntrsorkc^.o rpcisario., r\ pbvidcdturbyScchonl?0Oolrhc
<br />litxtr C{xlc. for rhe ri.rf.rnBncc olrhc *ori lor which rhc osmir n h\ucd
<br />I hlic r.d s ill nrn{anr workf\' .o p.ns3ri(r in\urancc. r\ rqunrd by Srcr i(h lTm or rhu hbor C.dc. Ior thc FrionmNc oi
<br />is pcflnir is ssu.d My workcr'con|fn\{n insurdi.c crricr drd Flicy nunrbcr dc\t'6
<br />II l/.
<br />-l
<br />LTnirlhrriflrlrc fcrlnflmnccol thc aork tu whichthis p.,Nn i( hsuL\I,I nrll nor cnrploy rny Fr{)n in trtry r$ncr
<br />$ .\ b lrconft sul,Jrcr i{, rlrc workcr( conrp.nsarn,n hws of Crlif{mir rnd a86c rhrr if I druld h.o'm subjc.r ro tlr
<br />qorkc^ .otrrp.nsrri.npnivhioNofS&rionl?(x)ofrhcUhorC(nnhwirh (mnly * irh rh.r povi\ions
<br />WARNINC: l:lilurc ro scurc workcn' conrpc.sarion covcmac r
<br />civil finc\ up to onc hundrcd thousond dollm (3100-0&). in .dd
<br />cmpk,ycr r0 dimitul ,xtuhi\ and
<br />i,r,. drn gc\ r\ tr'f!nlcd ntr llrc
<br />Sec'ion .1u70 ol rh. Llbor Codc-ircrc{
<br />",. ' (r'A'\Y
<br />DECI,AT{ITN
<br />I hcrhy nflnm u.drr lrnrlry of pcrjrry rhrr I rfl liccn{J undcr rnrlnnr or Chiprd I (.o nRN ir! wilh SNi(,n 7(fir) ol Divisi,r l
<br />or rhc Bulircss and Pmn$io,N Codc. aftj my liccn{ is in tnllli,rccudcntcr
<br />bq17 .-,.",*,(
<br />I h.rchy dfirm nnder Fnalry of F.ju'y rhar rhcrc n n consrocrio. lc
<br />nsucd (Scc.109?. Civ. C,.
<br />ollhc work lbr *hicn lhis Fnnir i{
<br />AITUCAXTDECIAAAU!}N
<br />lhcicsrulllnn undcr pualryotpcrjury ore offic nnbrin8 d(karii,ns:
<br />Dcmolirion Pcrmils'Asbcslos Notifi clrion Fcdcrol Rcsularions (Tnt 40. Pan6)
<br />-Rcrluted
<br />trn$ ol Nolilrarion
<br />I ccniltrhrrrhr lidc'rlrctrhri,,D\.cgiding rsh.{o\ tunn,vxLrr. mrxt)plcrhl. kr nn! p'(r..1
<br />$r.cn,ri rhd I hN.,ca.r rr,i1 4di.d
<br />oRtnrn.c\ Md Shrc Lra\ r.Lrin! ro bui
<br />rh'rc trrctrri{'nclIroP!nyl{tri'$purri,'n
<br />rde crhd lhc drnr inioanltiotr ncord.lI3Br..o rdy$irhlllCirydndColiry
<br />aurho.iz! Eprcsntlrncs of rhn Ciry and Connr, ro.nio uF,n th.
<br />/\ppliunl.r Alctrt Si!trhlurr
<br />l'r.milt. nrE(t,rinl):K v
<br />{
<br />W <nuw
<br />b'u ^(
<br />I
<br />COMMENTS
<br />"*" i Ll
<br />L:ndo's Addr$\
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