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BUILDING- INSPECTOB RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS olvNF:R Iu[,r)uR t)t,]t,cAR floN
<br />I hcrcr, arin undcr p.ndry or prjury rhd I m cxcdpr fn)m rhc ConrEcro6 I-iccnsc l trrv nr Ue iollo{inr ue,n (scc 70.11 5
<br />Bulincs lrxl fiolc$ion Codc): Any City or Counr, whi.h rcqutc\ a Fnhir k, .on{flcr. alrcr. impmle. dcn,lish or rlrrJn rny
<br />ifl.rxr., rriir b ir\ n\unmc. rho rcquircs lhc rpnlicrnr fo nrh r.flnil ro filc! siSncd slrtcncnr (h,r hcor rhc t liccnscd Nruanr
<br />k rhc pmviions ol rhc Conlmctois Liccnscd Lrw (Chnflcr 9. Co'nmcn.i'rg wiih Sc.rnrn 70fi) ol Divisio. -l ol rh. Busiirs rnd
<br />Pmrcs\n)n\Codc)orrhalhcorshc hcxcoar rhcrcliomrnd rhc Msh Lr rhcrllc8cdctcm ion Any vi.hrionol ScdioD 70.11.5 hyany
<br />3lr,licnni Iorr p.nnii suhj..( rhc nplli.ani bacivilpcnrlryorn.l nmrc than fi1r hundrcd dolh6 (s5m)
<br />I. tr\ .*io of r hc ptup.nt, or ni, cnll)brr.\ sirh w!3cs or rhcn vnc conDcnsariotr. uill do rh. wo* nnd lnc nmrurc h mr
<br />inrcnlcd orotir.d tu s0lc (SN 704-1. Busincs.nd Pn,f.rsi(,n\ Codq Th. Co .rctr's Li.cnsc Liw do.s nor +ply tu rnowmr.f
<br />rhcpn'p.ny w}r, buildsor imtm6 rhcF,n. ud shodessuchw* hnnsclforhcrcllorrimn8hhnorhcrowncnrloyccs,
<br />piovidc.l rlDr su.h inlNwnEnr\ N rn imcnd.d or dfl.rcd li,. $b lI howcvcl rhc buildins or inDmrcmnr h solil withrn .nc ,Tar
<br />otonllllclirn. rhc Owrcr Buil]d willhrv. rhc hurdc^.f pmvi',8 llu h. o! dr did mr lilikl or iroroE rhc ptup.n, ror rh. nuqr,*.f
<br />l. rsow.crolrhcrropdy, an.x.lu{vcly.onrEcrils siih liccnsdconlncloRrnconslrucltfic Injccr (Scc 7(It4.8ulncrs
<br />lnd ltofeshnCodcr'I h. Conrr.ctor's Li.ctrsc Lrw d,r\ nor lpplr to an o$ncr ol pn,prny who buinls or nnrnvc\ rhcrcod-
<br />.nil who €nrra ftn such pmj(h wnh a conrrclo(o liccned purunnl ro fir coDr..rocs Liccnec ljw)
<br />lr rcrc
<br />'tn
<br />undc, Sc.r
<br />Dnt€ O*n.r-
<br />woRrcRsL-atrrPlrf is,rTldN
<br />DEIL$AIION
<br />I hcrchy rinrn undcr p.mlryofpcrjury o0. oithc l.lbwiry dcclfl ionsl
<br />Ihavc!.dwillminroinoCcrriricrrcofConscnrrosclf-lNurcrorwork.(.omNtrs,bon.asrolidcdrbrbys{!i.nlrmof'h.
<br />Litxr Codc- lbrrhcpcllo,ntrtrccoirhc wort for which lhc tl.nnir i\ isucd.
<br />-l
<br />hatt od will nrinrnin workcs' .omprnsrrn,n inrdrucc. rs rcqutcd 6y Ssi ion l7m oi rhc l.iho. Code. [n rhc pe orrorcc of
<br />r\c trorl'nrqhrhrl".,Enn r. r*dcJ Vys'{\.!,rn'I'.tr{r',,n.ru,,,,r.anHrft]p,l )nunficd.
<br />c.**'.^^/^.**r*L.ffi
<br />_l cc ililhn( in rlc lj.nnrnrm. ol rhc s.rt lar qhichrhi\ pcrmir is hsucd.l \halln.l cnrtloyanrlr.non inrnrronncr
<br />$ mr. tFcon* uhjccr to rhc sorkcr o,npcnn(ion hus olcrlirohir n6d ngec th l ill sh.uld t conf, subjNI ro lhc
<br />woac* corracnslrion !rcvnions of Sccl bn .U([) ol thc rnnr Cix]c. I sh l. lonhsirh comply qilh rtu* Fbvisiotrs
<br />WARNIN(; filr'c r) $.0r. (r*rri is utrhsful. md shill suhr.l !n cnrloycr
<br />.ivrl lnr\ ur, h onc hutrllrcd rholsrnd do )). in addirion ro thc o\r oi compcns{rt,n- da'M
<br />S..ror 1l)ra ul rr'.li'litr( !i{lc n.s\r m,l ntr
<br />s/]1/t{
<br />u!!L lt!!.Itl)!
<br />I hcrebyalfinnundcr pcnllryol'pcrjury rhnr I 0m li.cnscd uM$ tlovnnn ofChap'cr 9 (.onnftnci.8 wi'h SNrion 7fi)) oaDivisio. l
<br />oi rhc Brsi.cs dd Pnnassioh\ Cod..,rxl
<br />'ny
<br />li.cn\c i\ in tuu iorcc aDd cl.lsr
<br />n,,,.,. ?Otlqt?z/zt/t6
<br />CANSIAUUIONIEIDINCIIiENII
<br />I hcrciy lmrm ufficr lcnalryolpcrj!ry lhal rherc n a conslmtiotr lcndinB.8crcy lor lhc pcrtbnnoncc olrhc work rhr -hich ihis pcrmn n
<br />issucd (Scc.l0C?. Civ C.).
<br />dIIIIIINLIJIiILIa^III]X
<br />l ltnhydin r dcr Itr trrlry of prjuryohr of rhc foll,)sing J.chBriotrs
<br />Dc hliri,)n Prnrir\ Asirno\ Norilicrrnn, Fr.dcral RcgulJrior\ ffill.,1(r. t'd6)
<br />RdqurcJ lxrr.roiNorlfic ion
<br />-l
<br />ccniiylh0lrhcli{cralrc8uhrions rcArdir8 dsh.{.s rc r)vrl &c ndr,,'t.dhlc u rhn t(,j..1
<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 />Framing (>!2-lg J.\at6't1
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handica p Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />A\
<br />FINAL 7-11")'i \ -\L/,1)l
<br />Certificate ol Occupanc \)v
<br />Notes, Remarks , EtC.
<br />I
<br />)
<br />Lxndcrs Addr.s
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