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BUILDING- INSPECTOR BECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS
<br />I. $ owncr or
<br />'hc lnrpcnr. or my cnplo)$r eirh wo8cs .s rhcn sob com!.nsal ion- *ill do rnc worl a.d rh. nturm n fr
<br />inrcndcd or oilced for $lc ( Ss 704,4, Busine$ .nd ttoac$ions Codc 'I hc Conrrachis l,icEn* hw docc nol |ldy x' m o$ncr o,
<br />rhc pDpcd, wfu) boilils or in fl*rs rh.Ki. ar*] slo des skh wo* hnn\.lf or h.r*lf oi rhn{8h his or hcr oun c'nploycc\.
<br />Dovidcd lh such nnDruv.nrflh !rc nol inrcndd o! ollcrcd f(, vlc ll ho*cq. rh. t'uill]iry or improtn.nr h k,ld uirhnr onc )Mr
<br />ofconrlndi.tr. ih.()wi$ BDildd willlrvc tl[ hudcn ofl,rovinS lhd hc or shc dd not huild or iry)rovc lhc lnpcny nn lh. rorliNc of
<br />l..sowncrolrhc nro!.ny. aDcxclusivclycona.lir8 wrh li.cnscn co rrcloF ro con(rucl l hc pmrccr (Scc 7orJ. Bunms\
<br />ud Ph,t6si,n Cone lhcConrracror'sLicenscl-awdoe!lorxpplybMo*ncrofpR)pcnyphobuildsorinlinveslhcrcon.
<br />rnd sho ontd.B ld such pr oJc.k wirh . Comd.ro(s) Iiccnscd l)usuMt ro tlr Conrracr{tr s l-iccn* Ils )
<br />Irn.xc rtrridcr S.crn .B &PC larrhi\rcrsotr
<br />Dile: OPDer:
<br />woRKERS', C(nrrPEftSATl(|l{
<br />DEIITIIAIIUN
<br />I hcrct y 0tfi.mDndcr Fnohy.f!.riuryorc.flhc follo$ins {iN,irolions:
<br />' Ihr\c d s'llrorirr'nJa.nrfildcolCnn{.nrr. \cll.ln\urc lnr q rlcF omFnqri r
<br />ritxr Cirdc. for lh. r.rfomMcc olrhc aork ror whi.h rhc pcrmn is i$tr.d
<br />r\ pnrnbd for b) Sc.rirnr:l7tn olrhc
<br />\rl-rq.\'rq\'rhhnnc'tr'i.'.u,1 MJ\,rla.',,nF-rri,{'r.u' h.,'r,- r"lt{,1.\ Lr'l\'.d.
<br />r-i, Stqfe t-nd
<br />Y..,,.,.,,,,,^., qzc 2 c /6 _-_E,* /o - | ? -Ze ,
<br />l..niryr[rri',rhcI.rlarrnai..ofrhcu.rklarshi.hrhispcnnir]\is\uctl.IshrllnolcorlloynnypcroninJn,,rnnrr
<br />\o s lo hccoN nrhl.d ro rlrc sorkcr omDcns ion h$roa(lliromii. ! rsrc. rhrr irl \houl(lh.(,N subjc.r tur,t
<br />workcrs'conrrnnrlnrntrovi\ionsofScclion.lTlx)ollhcl-rnrr(lic.l\k'll.r.nhwilhconrly$irhrln,{provi\tun\
<br />1VARNIN(i lrritrc k) rcrrc $ork.ri c. rFn\dn,n
<br />civil fint\ ut k) of. htr rcd rhou\and drlhn (lllx
<br />S.cri.n.1076.i11[ I r})(rCodc. intcrc{ rtrtlritnml \
<br />'rul. rnd (hrll suni(r rtr cnnl.]cr lo .nmi,rllr rlr xnd
<br />t, rh..oi of.onrEnsdiotr. drnrscs rs nnrlnlcJ nx ihr
<br />y,,,,,", l- 3D 'Zt)
<br />DECIdAAIIQN
<br />I hcrcbylrfiirnundcr pctrlltyo{Frjurr rhor I !'n liensd trndcr tovnn'n orCh,rln 9 (connrncing eilh Sccli{,n 7(x)() ol Oieisioi.l
<br />.t rhc Busitrc$ ond lhrn$ions Codc, lrd my liccnsc G in iull fore ,Jld c,Iecr
<br />n,.
<br />&,.
<br />a-3q o
<br />1-$o -fi *",*^, oro.,S-ercn'c" rio649c44
<br />lllrltrlll.IlllllJll]lj(i]niEJ(I
<br />Ihcruhy,ffinnudcrlInrllyofpcrjuryth.rrh.rcisa.onsodionkrndirBo8ctrcyforrhcpcrlornunccofrhcworkf{,*h'.hrhFFi is
<br />nsucd (Ss.:1097. Ci! C )
<br />txndcis Namc
<br />Lctrdcr. Addrcs:
<br />-
<br />ATIIICANLDII;ITIAAION
<br />I lf,n$y nfiim undcr l)cnnlry oI pcrjury onc ofrh. fdlowing d(lMrn,ns
<br />l)cnrlirion l'cnnils Asbcslos N.rillcari,,n Ftdcral Rc3rhriinN Ifib,10, fth6)
<br />R.quncd Irlrror Norill. rinr
<br />-l
<br />ccniryrhor rhc itdcrol rc8ulari{rN r\h-(os'rnniHlxr. ror rtnl'crbk n, rIn t'r]r.r
<br />!.*,,,'u,,,:,ci!.rl, .,r,,r rhdrhdrhrv. orrdior tcor.cl.I r!rcc hconrplt*irhrllCiryrtrd C trfty
<br />rnnr. o hcrchyrurlxtrizc rcprcscnrsrilc\ ofrhh Ciry rnd C.unlyro cnlcr utonltE
<br />rhk nrnri{nr{l nn)n ny lor ins
<br />)
<br />P€mir& n.me lFinr)t<t/4zet/LZ
<br />/ 40-zo
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsu lation
<br />Roof Sheathinq a bl-?lt /1,w2'z'/
<br />Shear Wall ur
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt, Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence (
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certil.
<br />FINAL 2 -/o-ze fuQto.t
<br />Certificate of Occupancy
<br />Notes, Remarks , EtC.
<br />\
<br />7
<br />Erection Pads
<br />'D/rA/l (
<br />oWNER AUII,DTJR DIiLCARATION
<br />I h.r.by rrfiiin uM$ Fn,lry of p.rjury ihal I .m crcnfl fmn rhc Conrlo6 Licn{ liu fitr rhc follo*ing rc.nnr (s& 7rrrl.r
<br />Busnr$ ..d Pnncrsn)n Codc) Any Cily or Counly *[(h r{nir$ a rEnnil ro con{rud- rlrcr. nnpr.vr, d.nn,lish or rclrln any
<br />nru.rurc- prnrn) ir\ hsurtuc. ho rcqunc\ rh.lPpltaDr t{n such pcnrir b lllcasSncd sd.nf, rhd hcor shc n liccnscd !u6u!nr
<br />ro rhc flolnions ofrhc Conlrlclors l,icensen L!$ (Chopr.r 9- ConnEncing wirh Sccrn,n 7ffX) of Divistun :1 ofth. Bu\ircss trn:l
<br />PnrrcslnnN c(d.) or rhsr hcorshc kcxcrpr rhcrcfionrnd rhc hrih f(trrh. rllcScd cxcnDrnnr. Aryviollri.nolScclion70.rI 5 h! rny
<br />imli.anr lor ! prnnil subje..h rhc aprlicanllo acivilpcnaltyoln.rnr8lhan fivc hl ndrrd dollar\ ( $5fi))
<br />I
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