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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. <br />/ <br />U <br />SITE-WORK <br />&qMr".( <br />--------r------ <br />----+--- <br />F--+-- <br />=