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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUII,DER D1]I-CARA'TION
<br />I hcrcby nfliri u.dcr pcnrlry or pcrjury rhnr ! dcrc,U lmrn thc Co mdo6 Liccnsc law for rhc n,lhwin8 rcrvrn (scc.7oll5
<br />Busnr$ il}] PmLssnnr Codc) Atry Cily or Coutrry wnich rcquircs r Fnnir lo c.rstud. nlr$, i'npror.. dcmlish o, m[lJt rtry
<br />slnrturc. prior lo irs ksu e. rho rcquirc\ ihc lppln! ror \x.h rtrnrir b filca si8trcd (.rcm rhar hcorshc n IccnsGr lursudr
<br />k, thc pmvhionr ofrlr Coitncrols Liccnrd Low (Ch0ptcr 9, ConnrEncing wirh S.crion TffX) of DivNion.l oi lhc lJu\incs ind
<br />PmLssiotrs Codc) or lhlI lE or shc h crcnrpr lhcrcaron ud lhe hrris lnr thc dlcgcd.rcnPtk,n AnyviohrnrnofSccrioi 70115 hy dny
<br />{Ilic! for ! ncrinit subjcchrhc applionr ro a.i!ilpun,lryorn.( m.rcrhln fivc hundrcddolllrsl$5Cn)
<br />l.r{oqncrofrhcltrop(ny.ortrrycnDloyc.\*irh*?!csn\rhrirs,lc.unrFnsrrn{.willd.rhcrrnk3rlrlrifl.rmi\ I
<br />idcn,lld oro,lcrd lbr slc (Sd ?O]-{. Busincss0Dd Pr.fcssi'nNCoJe I hc Conk rktr\ Lien\c h* d..\ tr.r rPrly rr M owtrcr ol
<br />rhc pmncdy Nho huild\ or inlpn)vc\ rlf,Rln. dd $h. d({\ n(h tr,rk hnn\cllor hcrcllor rhoulh hr or hcr o$n.nl)loyc.\,
<br />prcvidcd rhr such nn!m\c"rnhlrc mr irr.frL1l or oILLyl i)r {,E ll hoqrvci, rhchtrrldrnror imfmrsrcnl nqrd sirhin.nc )tr
<br />olconlPlcrion. ihc Osmr BuihLr Nillhr\d rh. hrdcnnfnniv'nu rhd h.,tr shc dil tror huikl.r iryDc rhc pnpcny for rh. ruqh{or
<br />L rsoskrorrh. lnottdt. rmcxclu\ivclyconlra.,ins wirh liccn\cJ cont .tn\ k,.oi{rucr llqnojccr lS(. r(}$. Bu\irf,r\
<br />. d PFissi,tr Codc '! hc Conlrocttr s l,iccnsr u* Joc\ nor im ly ro an o*trcr ol p,ot).a y *h. huil& or nnPhv.s rh$.oi.
<br />lDd who conrrrrs tur \uch tn!c.( wirh d Contrttr( I li.cnscd tursurnl k, llE Conrrrcr, \ l-(trs trw )
<br />_l lncxcmtr rtrdcr Scdn r . B & PC loithis cJur
<br />D.lr: ORne.l
<br />WoRKERS' C'OMPONS,\ iON
<br />l][lldaauo!
<br />I h.rchyrlftmund.rF,ndlryoit{rJltryoncoirnclolh*inEdcchn i,nN:
<br />-l
<br />hrvc i will Erintdn n ccnillcrrc of Conrcni lo Scl,:lnntrc lor workcm co'npctrsrtrn, ds providcd ld hy scdn,n ]Tm o f Oc
<br />t hor Co{c, lbr Ihc pcrlbrmuce ol rhc work for shth rhc p.imit is h cd.
<br />ihc $ ork ntr $ hi.h rhi\ |tr iiir lr ls{cd My w.rkcr' !_onrn n\rtio, iNUrnnc Gnicr ,,xl ,Ili.y Nnrtlcr .rc:
<br />l.cdifyrlrr ir rlk |xn.irnrmc of rlt work turtrhkhrhi\pc nir N is\ucd.I slmllnol.mnk,yrnyPc^on i. dy minrcr
<br />\i tr\ n, hc(nN $hr!r t, rhc s.rrcrr ornoctrsrt i(D htr\ oI Crlilhrnir md lgm rhrr if I \hould hc.om suhjcd ro I hc
<br />$orkdr\ .onrF srn fn)viii.ns ofsccriotr lTu) olrhc l-ltnr codc. l \lL l. fonhsirh ronplt eirh rh.* lrovhions
<br />$ARNINC: F_rilur k) *.urc w.rktn $nlrtrr tnr.ovcr Ec rs urhNlul. rnd \hrll slhJccr xh cnrPk,ycr to rniml t^-mlrts lnd
<br />(iril litr.\ un ro onc hunlr.d rh.r\riJ dolhr lSllXr.rXl)). rtr ndlii
<br />Sccrit)n.11176dlrhr l,rhtr ('t .. tr .rc{ rnd 0nonf,y'\ l.c\
<br />DC:
<br />I h..rbtrlft ,utrrlcrFfxhr0lD.rlurr_rhr I rrlicctrvdun'l$lxni\ol Chqr.r 'r (.onnrEN inE wilhS..riD 7(XXr).1D'risii l
<br />ol rhc Bu\inc\\rna ltolc$nn\ C.dc. Nd nr)_ 1r.tr{ n ir tull,nr.c iricllccr
<br />I hcrcby aliirnru crpcnJlryorFrrjryllt rhcr.hr(!triru.ri( lcndilr.firlcrylo'rhcp.r,onmn.corihcs.rklhtRhichrhi\F-nniris
<br />i\\u.d (Scc ltD7. Civ C.)
<br />AITLIIANI.IIECI.ASAIIAN
<br />I h@$y.timundcr ptnolry oaFrjtrry onc ofrhc rolk,wn't del nlt,'\:
<br />Dcnblirbn Pcrnrir* strnos Notinc(ion ltdcral Rc8uhr ion! ('l nk ll{). Pan6)
<br />Rcqunc{ Lcttcr olNolifi coliotr
<br />_l.orilvrhx( rh. llllrr]r.grLltrnN rgnklne n\h.{o! r.innil c tror rpplrrhl. r,Iln\ l)rt,j..r
<br />l.cnify lhar I hnvc rcad this applicrlion axl dar. rh r rlE rrsvc inimrrion is.omcl. I rgEe ro conPly wnh nll Cily Md County
<br />H::::il#::-t# : -*I:"":;d.pemirN Nmc rprrn''| I
<br />Set Backs
<br />Forms/Steel/Holdowns ('rl r+i{,{}
<br />Erection Pads (l
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVlnsulation
<br />Roof Sheathinq
<br />Shear Wall At
<br />Framino 7 lt(t
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lt/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Reporl
<br />Flood Zone Cerlif .
<br />FINAL lt )o" *-orrl "D/Certif icate ol Occu n
<br />Notes, Remarks, Etc
<br />h rhc con orco lpcnsrrion. dtrnr{c\ s\ rovidcd lnr rhc
<br />Lrnd r Nrmc
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