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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS o\!Ntit{ Br.rlt_Dt:t( D!:l,c RAT()N
<br />I lErchy .llrm lndcr rcnrlly ol ncriury rhar I am cicmd iiod rhc Conrh.tls' Ltcn* tjw tit lhc n'l!,*in8 rc&,n lscr.70ll 5
<br />Irminc$ r Prna$n n Cclc): Any Ciry or C.lnty *hich rcquircs. l.m lo conslru.l. rlicr, imtft vc. rhnolish r Elutr.ny
<br />irucruc. t ior ro ns i\suatur, also rcqutcslhc lpplicanr tut sochtcimir kr ilc, siSncd stltcmc lhat hcor snc i! liccnvd pestanr
<br />ro rh. provisions ol rlE G,rrr!cr$\ l,icn\cJ lis (Chdfl.i 9. C.mmncin-! wilh Sccrirn 7UX) ol Divirion I ofrhc ausrcs atul
<br />Prnt$n,ns O,Jcl or rhar rE (, \h. L( crcmpr rhc.rtum atrd rhc hasis tu lhc alhscd crcm/oo. Any viol.rion or S(rion r03l .5 by tny
<br />dtpli.anl fur n lcmir srbj$rs rlr aDpliunr b a rilil ocmhy of nor mn rhi6 livc hu.lrcd dolldr ($500)
<br />-1,
<br />!r own r ur tl[ prop.n y, or ny cmployces vi h vsscs us lhct soL omp.nsar 'o.. w dol}rwolk.ndlh. stmlEc i3 rcr
<br />inrenlcd or offcicd tur salc (S.c.?O44, Busi,rcs.n! hrlcssnns CGic:Thc Cohracu\ I-L.n* tiq docs nol !!tly nr !n o*nerol
<br />rhc D$ncny who luil(!{r ml)n)ws rhcN,n, arrl sll, dfts \kh w.rk hrms.llor h.r$lfor throufinn or hc. own.6tb]cc!.
<br />pn,vidL{ rhat slch iml,o$mnrs dc nor ir .d.d r .ftq.{ tu eL. lt. howctr, rtf, blitlins ol rririn,tmnt is old wirhin onc }et
<br />ol comp!:ri,,tr. rlE Owncr Bu ].ruil hnr Uc builcn of pn)v[8 lhd h. orshe dil Bn huill ot nn{rov. rhc JtrotEr, lnr rh. N4Ds ol
<br />Lrsowkr.flhcpn'F-ny.lar.r.htrrvcly.o.rdirfwirhlir.rdlc.nki(nsbcon{rucrrhcF+cr(S&.?o.lt,Ausrs
<br />! hni$irn Co'lc: l hc Contacttr \ I-r.nsc Lf,w JNs trol ipfly b o*ncrolprupcrlywh,)buiusortntn,vcslh.rcon,
<br />and wh. soft.ch 16! su.h pr{Iccls * h a Conrra.td \ ) ltc.s.'l tui\udr r, rh. Cdnktktr's LEn}c Lf,w)
<br />I Mrc\cmpt undcr Sc.l
<br />!aB.[EBlCa!!EE!l rloN
<br />DECLANATION
<br />I hcrchyull,rmunJcr pcndry ol p.rjury otu o, rh.,(nbwrg d(-ldah trs
<br />_Ih,!c.ndwillmn a u C.niticarc oio)ns.nr xr Scl,:lNurc tur workcN'conrcnsali(,n, is ln'viJei,tr hySc.rnh 1700orrhc
<br />tihor Cdc, i.r rhc nc.,i)rumc oi rhc *ork for wli.h rhc ncmn ir irsucd
<br />'ffiIIlc lill mrinhin sorkch conFn*rn,n i'sura,u., as rcqutcn by Sc(rion 37OO ol rhc Lhor Cill., r,tr rhc Pcftnmtuc ol
<br />rlNw lli{U1L'hrl'\n"mr'\'{u.dM}w,{rd.'lonrtcnsJrr.nrnsrmntc,dnh,u'JF,li rndf,h.r dc'91.^\ < f-t nt\
<br />p,,ricyNumhc -- g c ?- €'\t1 er""-, Ia-\ -Ll
<br />._l ccdlly ihar nr rhc Frtoirnrncc olthc work ltr v[i.h rhis pclNr is i!su.d, I shru nor cmrLy uny lcnon in any manncr
<br />$) A to hceom suhFll ro rlr ao,kc* coq.nsarioh l,wr.rcalbrni., akl.8rc rlDr ilI shrt!]bc$ft subi.( ro rh.
<br />wo.6'.omp.nsdronpovrsonsorseLon.l?(rjofrhcLnbrCo<lc,Irtull.Lnhqirhrohfl,wilhtl$$I'n)vnions.
<br />WARNING Fdlurc to Bulc mrkcr' .ompcnsarii,n rolcBac N unhwtnl. and shrll suhjel .n cmploycr n, .riminal ,cmlri\ 3ft1
<br />.ivii ,lncs up ro otrc hunJrcd lhous.rl Jdllas (Sl(x),Un). in aJdir l k) rh.o( ol.ompcns{rion, d,n!3cs as !n,vi.l.,l I 'r'.s(!r!r) rr)?..r rlr ljihtrc.dd. nn..r{,nl rr
<br />l-:Lo -'t L,C<;,(
<br />DEE! A{MX
<br />IhcmhydfttnLndcrpcmhyollcrNiyrharIanrliccn*dnDdcrprovrsi.nolChrtrn9(corn*nc,ngqdhScclNn7000).lOrvi\n,nl
<br />ol rhc Br{nc$ and Pnn.snor\ CoJc, mylicctrsc is h'llli)(r an'lcllc(l
<br />. f,r c ,,".-,,,,*. -t-1(Bs1
<br />{-Lc -a \ con J AJ
<br />CONSTRUCTION LENDING AGANCY
<br />I hcrby af|rd und$ Fnixy ol pcrlury lhal thsc is a ronnoclion ,endhc ascncy tur rh. I.rfomNc of lnc wrk lor vhicn $i Fd n
<br />issEd (Scc. 1097, Ci!, C,).
<br />APPL!CANT DECLARATION
<br />IlIEby t-mn!nicrpcnrhyotp.rjuryoncorlhctu,rwnr!dccldarn,ns:
<br />Dcd,l nJn P.rfrreAsh.sos Nolifi.atiotr lcicral Rc8uhrn,ns Gnk 40. P,n6)
<br />Rcqutrcd kttcr oi Ndinu{li,,n
<br />[lcnr,yrhrr,hcrcdcrdlr.iuLrrn\rsdJ,nE,.k{urr.mvald(n uflllh.hkt.rh\I'nFI
<br />_l c.niti ih.t I lulc rc rhn applnarn,n lBr narc rh,t rlr ubvc hlnmBion ir.oncl.l asre t, comply wirh,u Cilyahd Connry
<br />odirort.s nnd Srarc tf,ws El,tmS ro bui[in8 custnElion. {nt hcrchyaurhtrd. r.Ircrnrarivcs ofthn Cilyand Colnryk, cor€r o[r,n rlt
<br />rrr)v. nrnrk,rlllrl,p!ny ntr nAIt.
<br />,\prli.anl or Asenl Si!trslu ,,'* \-?r. -jL L
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Exl./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />II rl
<br />FINAL 7 l{l"t D/t+r{t//
<br />Certif icate oI Occupancy
<br />Notes, Remarks, Etc
<br />Erection Pads
<br />Flood Zone Certif .
<br />l)rre _
<br />LcnJo's A.l,jlc}:
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