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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE IDiSIG,COMMENTS OWNEN AUILDER DEt,CARAT'ION
<br />l hcrcby lmrm undcr pcnalry ol Friury rhar l m crcopr r!'n rh. G)nra.ro6 Liccnkhwforrtu6llowingee$n(Ss?0115.
<br />Bu\incs rrd Polcs\ion Cod.): Any Ciry or Counry shih r{toircs d Frmir ro .otrerucr, !lt.r. inlttr0ve. dci.lhh nr Rn,n rn)
<br />srucrric, rri,, ro irs is\urtuc. 0lso rcqu,rcs rh. +pli.r.t for su.h Frmir ro filc a sirncd ({rcmn! rtur hc or shc t li.cn*d Nisurnr
<br />ro rh. pn)visn,ns of rhc Crnrhckr's Li.cn{d Law (Chnpr$ 9, C.m rncin8 Firh Scclion ro!X) ol Divhion I ofrne Bu\n[s1snd
<br />PmnsionsCodc) orihar hcorshc iscx.mpt rhcrcfron.nd rhcbasi\ io,rhc all.scd cicnurion AnyvioltuonorsNtrnT03l5byrtry
<br />Btplicanl foraI'cnnir srbjcclsrhc 4rrlicairk,acivilFoolryolnolnDrcrhJnfivchundndd.uds($5tx)).
<br />l. o{ncr oarhc pn,lleny, or mrcnfkJycc\ wirh sascs n\ rhcn $k ompc.sarion. willdo lhc wod md lhc srdlh il nor
<br />imcndcd oron red rdslc(Scc 70{4. Busincss d Ptuacs'onscnlc Thc Contracroi. Li.cnE lisdocan.r ryplyroanowNof
<br />rh.pmFny who tuilds or inqmws rh.m.. rJd who dms skh uork hi'n{lfor h.^clfo! thmu8h hn or hc! owocmplo}cc\,
<br />nrovidcd rhat such impmvcmnr\ ec mr idcnded or oftcEd ior sb lt imME, Lte hoilding or iftln,kmnr is $ld wirhin oN )tu
<br />orcdnpLrbn. rhc o,n.. Buiticr will harc dE bunLn ol pmvins fid tE or snc dil rcl I'oild or inrmt rh. rmFdy ror rhc lury$ of
<br />_1. a\ o*ncrolrhc pmrcny. lnr.klu\ivclrconkrrn,E *irh li.cnscd coikd.roN ro..nnru.r rh. p(+cr rse. 7in4- Bu$ncs
<br />oxl Plofsshn Codc _IhcConrroror'sl,iccnscl-awd.cs.ollDolybanosncrolpropcn!*hohuild\ornnprovcsrhcrcon.
<br />rtrd wh. .ontrrsturs h tmjc.t\ wirh r C.nkact (\ ) lircn\dd Nrsr rrorhcCoffdq s Lian{ tlwl
<br />-l
<br />amexcmrr undcr Sccrn,Il & I)( litr rl'n r.tr{nr
<br />OPner:
<br />IIABSEIIi:(AMIEIIAIION
<br />DECI ANAT(IN
<br />I l.nrct y atfirnr undc! Fnalry otprr!ry.n. ofrhc tuln,*nrt dslxrari{nN
<br />-l
<br />hlvc and will mintoir !CcnificarcofConsnr roScltln\urc lor worl.ts'c.n{rns,ton. ds providcd lbr bySccrion.!7(norrhd
<br />Ijbor Codc. for thc pcriormnccoflhc woli for whichthc pnnit is isucd.
<br />-lh0vcrnd
<br />will mainhin workcs conr|enslrin insuruncc. !\ rcqDn d brS.dnrn lTmofrhc tibor Codc.lor lhc pcrloil rEcof
<br />rhc work r'or which lhis pcnni is i\\ucd M,workcN comncn\trinnr i'NurM.c cMi$,nd loli.y nurnbcr rc:
<br />I c.niry rhar in rhc pcdormEc ollhc wort for which rhn Frmir is nsucd. I $rll nor.mpk,t any lciso. in any manncr
<br />$ $lo bc.onE subjcct to th. workcF c mpcn$rion la*\ olCllifon,ix. r d.gtc (h,r irI should lEtoE sub,cd ro rh.
<br />sr*cr' comn nsrion F,vhion\ of Scdnnr :llm of rhc ljbr Codc, I \h3ll. ionhwirh conrply wirh lhoc tmvisioo\
<br />WARNING Flilurc h *curc aolkcs omp€mtrliotr covcrlSc is lolosful, ,nd ihrll subjccr 0n c$Ploycr ro qiminrl pcnalric\ rnd
<br />civil n.cs up lo oN hundrcd lhousrtrd dollors ($100.000), in addiri.n k, rhc c.s orconwtrstrlion. drnEsc\ as tmlidcd rd rh.
<br />Sdion 1076 ol$e ljlxtr Codc, itrlcrcslrnd {rlure}} r'as
<br />ucliNsf,rleoNr3 slQaDttr .E.rlla!
<br />I h.rchy llttni rnd.r ntndryorp.riury rhar I an licnrrl und$ r,otishn ofChapter 9 (ommmins wnh s..rio. ?000) olDiri\ion l
<br />ol thc Ausincss and Pmfcssions Codc, ad ny lkc.\e ir i. fnll ttrcc rd .net
<br />I iccn\cc[\\: Li.c \c Numh"r
<br />IONSIIIJCII!.|N.LENDINGIIiENT.I
<br />t h.rhy drfirm undd lrtukyorp.rjury rhar rhcrc r..nnslflct$tr lcndin8 a8cmy ior rhc Fraorronc. drrh. work for which rhn P.r!i n
<br />i\sucd(S( :1097- Civ C )
<br />A.TIUCANLDECLAEIII9N
<br />I rrRhlafiimutuicr pcmlry orpcrjury otrc ollhc hlhwnrS d.ilrtrrliors:
<br />l}!nrnii,'n Peflniis Ashcnos Norili.rrnrn F.dcralR.Sullt(rr\ ('Iirl.41). Prn6)
<br />-Rcqun
<br />d tr crof Norilrdidr
<br />l.cni[ rhd rhc ndcral rcsulaiion\ esd in8 a\tr{o! rcB)vrl rr nor +tliGb]c rr rhis ptuF.r
<br />I ccdilyrh.r I h!!c rciil rhis apnliurin md nrrc rh llN lh,rc i!tuiitu io. n ..ftNr. l .3re ro conDly *nh rll Cnr rnd Cornry
<br />oilimn csmd Srrlc Ljws rcl.tinsIo huildinscon(ruclion. lnd lErch,ru(htrizc rcPrcrnrarivc{olrhis CiryrtulCounlyt,. rcr uB rlf,
<br />rh,vc
<br />'mnr
<br />ioicd Impcn y fr inspc.rtnt lurlbsr
<br />Appli.nrt or AActrl Si8nolurc:
<br />l'c.n lre ntrnE(prinl):
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Ve nt/ ln s u latio n
<br />Rool Sheathino
<br />Shear Wall
<br />Framing
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Beport
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL 9/7ltg ,.u4{D
<br />Certilicate of Occu Ipancy
<br />Notes, Remarks, Etc
<br />l.ntlcr's AddrcI'
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