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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE tD/stG.COMMENTS OWNtrI( 6UI LDI]R DELC,TILA'TI{JN
<br />I h.rcby ni,irn undcr pcnalry of pcrjury rhur I m cxcnrpr lro'n rhe ConrftcroF l-iccn{ b* r$ ih. r.llowing n.v,r (Scc.70ll.5
<br />Businc\\ lnl Prolcsioi Code) ny Cir, or Couni, shth rcqune\ a Fhrir k, cotr{ru.r. nxcr, nnprolc. dcndirh , r rcrrr rny
<br />srucrurc, pri)r ro irs issu.kr. olso r.quircs rhcappliclnr fLtr such Fnnil ro ljlcr sisncd d3tcnrnr rhrr h..rrhc n li.cn(,| luhd;r
<br />ro rhc povNions.frhc Conlri.bfs Licctrsci hw (Ch0lcr 9. Connncncirg wilh Sccrion ?(x)0 ol Dili\ion I ofrhc Bu\ihcs rnd
<br />P.ote$ionsCodc)orthll he or shc iscrempr rhcrclromrnd rhc hosi\ for rh. dhacd cxcnfrion AtryviobrnrotScdionT0:ll5hylny
<br />artlica.r tur!pcrdir subjfth rh. appti.0mrorcivilpcnrhyornor,tur.rhdnfivchundrcddollrs(S5txr)
<br />-1,
<br />ds owns .l ric pmpcny. or my emplo,€c! *irh uscs !s rhcir n,lc .norr.n\rr io1. will do Ihc wolk ond tlt sltrture is ft'r
<br />iircnd.i or oitclcd tor $lc (S( ?0,14. Blsincs lnd Profcssi,ns Cdlc I h. Conhrtr\ Lic.ns hw dms not {'!ly lo m owncr ol
<br />rlE lmNny *ho huild. or nllpmrs rh.Nn..nd who dms skh *u* hnnscllor h.r*llor rhmqh ht or hcr owncnpl.yc.s,
<br />pK,vidcd rhi such imtnvcmnh m .or inrcnded or oftta'd for st ltl ho*clci rh. hiHing or nqrotmnr is bH qirhin orc Nr
<br />ol coflpbtnnr Ihc Owncr Aui&r sill ha'! rhc ttr'dcn or provi![ lh{ hc or \hc dil nor huik] or i'npmw ilr lmrsy ror rhc N!,s oI
<br />l. *ownc'ofrhc ln,tdy, dfl.x.hsivcly.ofta.rin! wiih liccnscd.onr rnsroconiru.trh.pmJcct{scc ?0,1j. Bu\incrl
<br />lrn Pbt$ion Codc 'l hc Conrracr 'sLicenscLawdoesnnronnlylonnownc.orpii,p. y*hobrildsori pi(res thcreotr.
<br />xnd sho co.tack ftr such piojers *i'h a Cofuacbin li.nscd ,,uisua.r k, rhc cbnt&lors Liccnsc ljw).
<br />I xn,clrnUn u J.r S..ri,,
<br />O,B
<br />uoaKISg(oufrNi rlt)x
<br />DliCLAtsAIIO!
<br />I hc,.hy irttn uDdcr l}:nilryoflcrjuronc ofrhc lnln,$in8 dcclifllions:
<br />-lhovclnd*illnuinrlinaCcnillcnrco{Con\cnrbSclflnsu,e.tn*orkcrrcont
<br />nqri()n.$ [ovidcdf.rhrsccli()n]7ol)oirhe
<br />tibor Code. lnr rhc !c om.c. ol rhc wo* fo. which rhc D.rmir i\ hsucJ
<br />I hrlr rnd willmrinrrin *o'kcrr coilprnsrrn,n in\urrncc. ns rquncd bySccrtrnr lTUrolrhc l-'horGrt. ntr rh. I[rfonNncc of
<br />ql,i!h 'ln t{nnir n n{f,Ll IIy,/-"/L.J r imuhNc caricr di policynumhcrd.
<br />7bd-tcAALk-z-
<br />llt.caily'h, ,n rhr lcrlo tun(c,,1thc trorl n{ *hich'hh pcfln[ n ksusl- I \hall nor ctrDl.yrnylrr$n ir,trymrtrrct
<br />\,i I r' hcn,m \uhlyr rn rhc tr, fl..onilrr.rtrn' rrw. nrC' ^'n'r. Jd r8'c. rhr 'll \hnuu f{c.rm \uhiR r rn rhc
<br />*o'kc*.t'nncisrri6npx'lhidn\ofSccriunl7(nofrhctjhrCrxl..llhlll.tunhwirhomplywilhrh.spre n,nt.
<br />WARNINGT Fdluro ro scurc workc6' c.nl*nsarion covcriBc n unh*hl. md \hall \thj(r an cnpk'rrr
<br />'o
<br />rinnnal FMlics lnd
<br />rivil fitrd\ utr r. oic hundrcd rhousnnd dolla( ($l(x),(XX
<br />Sccrn,n :107i of rhr t2b.r CoJd. inr.rce n.d inormv l fes
<br />)). ir nddiridr to rltr co{ oi conrl'tnrri{)n- dr,
<br />"",.'bs1 D
<br />^ppticntl
<br />llxcl -8rlr!l!
<br />I h.dhy rflt r ui .r r( rlrrol t,crlury rhd I Un irwl uMcr fl ovisio ol Clulrc! 9 (onn,*m in! sirhSccriotr 7000)
<br />.l rhc Brsi.es md P6fcssn,n\Codc. drl nyli.cns. i\ in lull f ...nd cflc.r
<br />7
<br />//r'tr -ez -a=-
<br />I hcrciy 0fiflnundcr pcnalryofpcrjury rh[l lhclc h a con{rucri(nr lcndi',s rrcncy ttr rhc P.rbnrun c oltlrc work tbr *hich rhis Fnnir i\
<br />irsucd rSc..1097, Civ. C.)
<br />APPLICANT DFCLARATION
<br />I tntby imunnrr pcnrlryofFrjuryonc oflhc lollowinE dcclarurions
<br />Dcmlirron Pcihn$Asb.slos Norifi.alion P,cdcral RcSul.rions (Tirlc 10. PM6)
<br />-Rcquncd
<br />kircr ol Nolifi clrion
<br />I cLnifrrh,r rhc fcd.rrl rcsuldtnr\ rgidin! ashc{o\rc n^ilrrc n.r.pnlicahlclo lhi\ prtcr
<br />lk;ir) rhrr rhrvc,ci,rrh'. r,,n 'c nn ifti rJ,c , h hc $.v. inr{rrorn,n i\ cotucr I rpre ro coDlpl, wirh .ll (- } and (bunit
<br />l{ffin]mc' rlsrriutrx.rchr[Erohurldtrtsc,nartucrn,n udhcrchyrurhniT.c,vc\cnrdivcso,rhncn,r Counry b cnrcr uIi,n rtt
<br />.ll^c ft trrt,ncd pii,Fn!,nr inspccrion
<br />lpprrcanr or,rrnr sigmrrrc {-
<br />ax-r(
<br />zLlz-
<br />Set Backs
<br />Formsi Steel/Holdowns
<br />Erection Pads
<br />Subf loor/VenVlnsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framin g
<br />lnsulation/Energy
<br />Drywall
<br />l\4ason ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Cenif
<br />FINAL )//r6h 7,-{te/o*
<br />Certilicate of 6ccupancy
<br />Notes, Remarks, Etc
<br />-t
<br />UFER Ground
<br />SLAB Floor
<br />Ext./lnt. Lath
<br />Brown Coat
<br />I
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