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BUILDING. INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS OWNER BUIT,DFJTI DELCARATION
<br />I hcrchy atfirm lndcr lcnrh, or pcrjury rhd I am.r.nnr rnJfr rhc conlractF Liccn\c L'* fitr rh. ronowins rci$i (S(?0.11.5
<br />Bu\inc$ and Pmrc\\ion codc) Atry Cily or O)utrly *ni.h rcquics a Frnir i. .oiirud. rlrcr. iny/nvc. {kmlhh nr rnrn Jny
<br />$rucrurc. priorro ns issuanc€.rhorcqut\rhclpplicrdrorru.hPtrmirrolllcrsiEncd(lrcmnl rhat ltor sh. ( li.cnkd ?uruatrl
<br />ro rh. rovnion\ orrhc Contrachrs Liccnscd L.w (Chaprcr 0. Conmncins sirh su.'ion r(xD ol Divisi0n 3 ol rh. Br\i".$ and
<br />P,olt*ionr c.dc)orthrl hc orshc hcxcnrl rhercfronand rhcbasn ior rhc ill.[cd cx.nPlion. AnyrnnrlionofSlrrntr?0]15 $yrtry
<br />rtplicontior.D.rmirsuhj(hrhc,mli.a.rba.ivilpcnahyorn.r'mrcthatrlivehundrcddollln($5uD
<br />I. oer$orrhc pn,lta!. or mycnuloyccs wilh wrscs 0r rhct 3,lc conrrcrsdiotr. Nilldo rhc Nork md rhc rltubto n nu'
<br />intndcd or ori'crcd rd {lc (SN 7l!4. Bxsincs and Pn,rcssi(,.s Codc Thc C.nk!.rols L,iccnse l-!* do.\ dor +lly kr an o{nct ol
<br />ihc pfl,pcny sh, hoildr or n!)orr rtEmn. urd who des $ch wo& hinscltor hc^clf.r rhough Lis or hcr own cmrt,y.cs.
<br />providcd rhar such in,pR,lc.rnN ftc mt inrcNlcd orollcreil f6soh li ho*cvcr, rhc tDikliis o! nnnrovcmol t$H *irhinotu rtrr
<br />olco'.pltriD. rhc {)sn$ Buildo willhalc rhc burdcn ofprovin8 that h. or she did nor hdild or ir{rovc rh. pnrFnr lorlh. purrx,v of
<br />-l.
<br />osncr.frhcpR,r.ny.! cr.lDsivcl, cont&rir8 *ilh liccnscd .o nck,\ ro cotrddcr rl'. r4Ltr (s.c 7(!4. ,]u\ir'c\\
<br />,M Pn,fGsi Codc: Thc Contmclois l-iccn€ l,as docs noralplrro anoairofPolc y who huilds or imPrintr {hcrotr.
<br />ind *ho codracls ior skh pn,j.ca wirh a coNncrdl s) h.cn{d lunuanl lo lhd contacror'\ Li..is rjw ).
<br />I ncxcn,prundcr S(r
<br />llaBKE&::laUruNSAllON
<br />lllgdaArloN
<br />Ih.tohynrri.mtr dc' llinrryolpcrjuryoncoflhcioll.uln.cdcclirdri,rN:
<br />lhrvda,xlsillmnniDaC.trifrarcofConscntroScllln\urclhrtrortsicohNnidnnr.asPmvidcdl'{)rbySrt1ir'nll00olrhc
<br />L{htr Grle. turrhc ocrnr [ncc.arhcworklorEhichthc|rnnit nis cd
<br />I hrvc rnd will nrimrin workcr\'compc!\arion insurrncc- rs Equ ncd $y Sc.rion lTrD ol rhc l-fior Codc. f.r I hc fl.rfonMNc of
<br />rhc w.rk ror w[i.hthis pci,nir is issued. My workcr' conrpensari,,n n$urr .c.rricr 0dplicynumhcr aE:
<br />-erpms:
<br />r
<br />lccdifyrhrr irrhctcri.rmrnlT.tthcsolk n i\\ucJ,I shnll nor .mflo, rny pcno h rdy rrnNr
<br />$ a\n'h{co'm \uhjccrri rhc sorkcrj.'(njrrsrr ilirnrix. trnd rgrcorhrr iIl \lx,uld hc$onE \uh]cd h rhc
<br />$ork.ri comNd\rri(h lari{on\ "l sr.ri,tr!.17()()I shrll. tunhwIh c.n10ly ]irh rho* In*i\i{nr\
<br />llAltNlNG li.nh,ru k, {.ur. {o'kc6 .. \,ci\[ni N unhstul. rnd \hrll suhic.r Jr. rd.r_ct o.riri',rrncnrhd rn,l
<br />{ddiri(r ro rhd c.{ ol .otrlrisrri, . drtrn8cs 3\ Jlovidrd 1,, rlr.ivil Inrcs up n, orc hr rcd rhousdnd dolldtr (sl
<br />Sccri,{r.1076ol rhcl,at)(rCoJ!.n .r.! drr
<br />,,," -O5:4"4p!6
<br />I hcrchyillirnrumlcr l]cnilly.lp.rJuryrhrr I nm li.c \L{vi\i( .l (-hxprd.9l.onnc rlrg rnh 5..r.n 7(nll)) ol I)nilor l
<br />of rh. Bxsin.$ rM Profcssi{nr Codc ! myliccn{ n in full for.. ktclltcr. .
<br />AL ACo3:-2\
<br />*" ggG?s&..,,*X\o:,nnlsGa$.r-\
<br />coNEralrq QNtllDlNc_dgINl}
<br />rsucd rSc. :1(197. (:i! (.)
<br />L.trJu \ Jdrc\!
<br />-
<br />I hc'r$IrlJnmurJ.r nJlr\.lN,Iry.
<br />Dcnrilirtr, Purnrirs A(r(os N(
<br />I..nIvrl'{ I h.v. r.rd rht lywnhollCiryrnd Cotrirt
<br />ny dnd Caunryh cnr.r uI!,n rhc
<br />5oAturb
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulalion
<br />Roof Sheathinq
<br />Shear Wall
<br />Framino ;-1-t6-De*(c4
<br />lnsu lation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar L-'t-\'0.\\"\An[.t I
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certil.
<br />A
<br />FINAL ta- lt- lv Y"\U1t,
<br />Certif icate of Occu anc
<br />Notes, Remarks, Etc.
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<br />SITE-WORK
<br />&qMr".(
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