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BUILDING- INSPECTOR RECOHD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER AUILDER DI'LCARATION
<br />I hcrchy rafinn trnd.r F_n,lly oi tcrjury lnal I ah crcnfr rmrn rhc Co r$ros l-ic.n\c Ir* fttr lhc ftnh{ing rctrqnr (SN 70315
<br />lJusincs rnl P(,fd*t,d Codc) Any Cily or Counry Nhi.h rLluircs a P.nnn t, c.nsfld. .her. imprrv.. .ltnxrsh or refrir rrv
<br />nrudu(. prid ro irs Gsurh-c. rho rcqun i thc aNlicdnr lor such Frdn k, filc , siSrEd slaleEnr ih{nc or sh. n li.cntd nusuanr
<br />ro rhc ForisidN or rlf, cont.crols l.iccnsd h* (ChnIrfi 9. Connncncin! wirh s.dl 70(xr nI Dithi.n I or'h Br(i'rcs I
<br />Pn,fc\\i,,n\ L'odc).r rhat h.oishc i\cicdpr rhcr.lioNaftl thclx$is ti)r lhc dlLldl.knrllio. AnylioirrionofS(thn?0ll5l,vahl
<br />aptli.rnr ror a |).rmir suhjcclrrhc tptli.unr ro tcivillrmllyornor 'fr,cthrn lirc hundtcddollr* (35(n).
<br />-l-
<br />N oqmrofrhc l,oFny. nr nry. itlortts wirh wrlcs a\ rhcn vnc.d D.nsation. {illdo rh. wo* fltl rhc srnf,rm i! nnt
<br />inr.n .d or orIcrcd lor srlc rS( 7(!4. au(incs ann hofc\\nnr Cd!: l hc Conkactr\ Lacn\c t $ doc\ nor tpplv lo m o* .r of
<br />rhrpmpcny wlF hxilds or iqxNcs rLr.\'n. $d wlm dms n'ch $ o,{ hnnsc ll or h.rrcll or rhn,u8h hn or hcr owi c tllovccs.
<br />providcd rhrr such itll(,v.mmmfrn inrcndcd orot1mlntr crlc.ll, ho$cvcr rlt huiLlnt or imPnNcnrot i\ sild silhinorc )ea!
<br />olconDlcrion.rh.O*.cr Buikcr willhalt rhcbnrdcnofnnrvinsrh lrc or shc Jid nor buikl or iryrov. rh. Imtf,ny for lbc puqn{ of
<br />l. r\o*ncrollhc pR)trn1-. rnc\.lNivclycontr ring$irIlNn\cLl.onrrrcnn!,.of(r1'crrh.PruJc.rlSc.7O4J.Bn\i't\\
<br />r t t\rla\\fl aoic lhc Cotrrrncin'\ l-i.ctrsc L.$ (locs tr.r xmly h r.trrcrolnron nyshobuilds ri'nnrolc\rhcr..f.
<br />rrn *ho cnntr.r\fdsu.httrolc.l\sirhrConnrn(\)li.dr\c(lPnr\uxnrt,rlfCofhi.rr'sLi..n\cl,rw)
<br />. a & PC ld ihi rrJun
<br />u0B[,[Bs:rI)ull)Ns/1IIoN
<br />D[CI.A.8{II!JN
<br />I hcrcby trf,irn untlcr p!ulry.ll.rjuryonc ofrhc lbUt,Nins d..ldflliotrr
<br />-lhrv.,ndwillminrainoCcnincar.ofcunscnrbSclfnrurcilr$brkc6
<br />omPcns ion. as flovi]cdlorbys.crbn17rn"rh'
<br />Labor Codc. r.r rh. FrfonMrcc of thc sod{ ror which rhc Fsn r is is\tcd
<br />-l
<br />h,r rnd sillmoinl0in so,kcts .omp.nssrion iNurancc. !\ t qun.d bySccrion]7moflh. b6o! C.dc. Lrthc FrrornEn" or
<br />rh. work rorwhichihn pcnnil is h\ncd. My workcn sml'cnslrioi in<unmc cmtr and r.lic, numbci m:
<br />l.cni(y lhol in rhc Fnnnnrftc otrhc trotk fo, shich rhir |fnnit h is\ucd- I \hrll nor cnrnlov 1nv nc'str in !trv manmr
<br />s n\ ro hcd,m subj{t ro rhc *o,tc^ confcn\.ri,,n Irwr ol'Crlirornir, and,8rcc llul if I \hruld bc.orft subjeci io rhc
<br />rorlcr\' co rpcnsrrion F,visi,)ns olSccrn lT(X) ollh.lrtnt Cixlc- l \hrll. f.nhsirhdnnnlysirhrhrc
<br />wAnNNG flilurc b {.urc trorkcn' comFnsarbn cokmec is utrlr*li'l md \h.ll suhi.rr an cnlplo
<br />.iril liNs u! ro onc hr ncd rhous. d dolhn (ll[).(lx)). i'i nd(tir,r r', rhc.o\r ol ..nurtr\xrirnr.
<br />Sccrir r.1076 olrhc lf,txtrC.dc, ! .rc{oiarrrr '2ogrn=
<br />I Dok:
<br />!ll!l-Bl!u
<br />I hcrhr rfln undd p.nilryol Frjtry I unde. lrrtri\i.i orChrprer I (.a'frftn.nr8 wilh Sccri,n 7(xxr)oil)iYhion.l
<br />ol rh. h'ri,E*xn,l Pnift$nrr! C.dc. lRl ,y li..r\. r fulllrn.. rnn.llicr
<br />o"",oOZS- t
<br />I hcrchy nnh, uMd lrnrliyofp.rjury rhrr
<br />is{rarscc :l(r'17 Civ C I
<br />is a con(rucrto. lcndi"! ogrncy ftr rhc pcrtunnr0cc oirh. \qk nr shi.h ihis Nni n
<br />APPLICANT DF(:I.ARATI(IN
<br />lhcr$yu,tmx.dd Fcn.lry ntrcrFry ore orrhc lollowtr8 dccharionsl
<br />Dcmolirion Pcrmih Asb.{os Notilicalion Fcd.ral RDgultrl ions Ont ll). Pan6)
<br />-Rcquircd
<br />tr(cr ol Nolirturhn
<br />l.rnrry rhnr rln' lirl.rxl icgtrlxri(n*'c riN r.nDilr( norrnnli.rhlc ro ihs ln,l-cl
<br />r -'!v'f r,"," -,a,r',. "nnr'*,nrd,niRcvl s,a,c I]*. r.l,r'ns ro hu
<br />rhrr'rcn^pFnci, nr n\rcrrion
<br />rlDlrl[rh,vcnrli).rorion i\cotrc.r I rsrerocon{l} LvnhlltCiryandCoutrr,
<br />rtr. '.|rc{ nc\ o, rh^a vIdli'xnryrn"F,nunnnrhc
<br />,,","o6-25-lgq E"+ )::::::v:"CAIL\^.-,>
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq tl1lr7,1/44t0)
<br />lnsulation/Enerqv )f:,-r
<br />Dryvvall )e/'{xt.l)nt. LaIh 7li1r9 -Aatf,t-B-rown Coat
<br />Itilasonry arrddLr, r;tr.h 't\ro\t4 L)Lq\o I )
<br />Pool Fence \l
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />FINAL T//r,/rs Lt *)r--.11,4 -t
<br />Certificate of Occupancy
<br />Notes, Femarks, Etc
<br />I la irr.,I
<br />)
<br />t^€dl
<br />OL
<br />Cani.l
<br />-
<br />E>/
<br />Lr.dcrr NanE'-
<br />l.1,ls'\ 4l'l'..\
<br />-
<br />Flood Zone Certif .
<br />,s^ ) r.,,.d aa ^e "!.l-' Lt,^ ,l,l;1 t,,,-<,
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