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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNII' BUILDIiN OI]LCARATION
<br />I hcr6y rlnnr undcr p.lalry (,i pcrjry rhlr I !n excmpr fr.m rhc c{,orB.xE l-i..n\d tlw ror rh. r(rbwi.8 rcr$tr (Sc.70115
<br />Buitrcs rt Pn,fcsshn Codc) An, Ciry or Counrt ahich requirus n Frrnil i' .urnru.r. ,lrc!. inDrovc. d.odnh or rcpat rtry
<br />ntudrrc, Pnrt, ih issuancc, ako r.quircsrhc upflicanr l'or .h prnir ro lilc r \igncd {drnrnt rh,r h..r sh. h li.ctrqd nusuntrr
<br />to rhc pD,nn'ns ol rhc Colrracrnt l,iccnsed ljw (Chryrcr 'r. Commcncin8 *irh Sccrion Tlxx) ot Dilist,n.l orrhc Burinr\\ and
<br />Pdt\siotrs Codc) or rhrr hc or sh. i\ cxempr rh.Etirom ud rh. lu\h ln rhc allcgcJ ci.nprion Any vi{,hrhn of SNrion l0l L5 by riy
<br />rfl,licrtrl ln r Frnrir subjc.rs rh. appli.anr rJn.ivilpcirkyofnor nucihatr nvc hu rcddoll*s(S5m).
<br />l. rs osRr .l r hc pmFny. .r my cnlro)r.s *irh sagcs ,! rhct v,lc .o'nptrs otr. 8,ll do thc rort md rhc slBlurc h nol
<br />inrcntxl oro{icr.dfor$lc(SG?0.1,1.BlsimssandI'ron$ionscodc|hcOrnrroctoisLiccnrL!$docsnorlpplybono*ncrof
<br />rhcF)pcdy who huild\or impmv.s rhctun, &d wh. d(n tuh mr* him{l{or h.r\.ltor thtuu8h hi\ or hcr os..mpl,'y.cs.
<br />proridcd rhrr su.h inll)R,rcnEn^arcfrn inhnicd .r oltlrual lor sih lll lDurcr, ihe hrikli',! or nq'dvc'hnr hn'ldwirhirotrc Fnr
<br />ol.ompldiotr. rhcOwncr Buildd wlllhrvr rh. burd.i ul rrolitrg rlLr hc or \hc did or lriltt.r nnlov.lhc pmpcn, iorrl[luqsrcof
<br />l. r o$ncr ol rh. nropcny- amcrclusivclyconrradiry wirh liccnsd conrracror ro .oDnrud rh. rn,jccr (s.t 7ol-{. Bunics\
<br />nnl [,lrrc$$n Codc Th. Conta.kx s Licctr\c L.s doc\ not ll! ly b in osncr ol trr|f Iy sho buil or i,npm!c{ rhcr.on.
<br />lnd who conrrrlsnn such lrojccrseirhaCo rrocro(,liccnrd pursurnr rorhcCo rrctn\ l"tccn* trw)
<br />-l
<br />ciempl undcrscclion .B &PC forlhisreosn
<br />]!llt!!Bt!Qr!r!!lt!lta-N
<br />!2I!L\Brl.IL2f
<br />I h$cb!rfinniurdrr!rnrlry.ifc'ju,yoic.f rhchlk,si'rgdr.hrrri,n,\:
<br />I hrvc dri sill @n ain , C.dilMrc of Coh{nr t, Sclt ln\xrc tur workds (nnl.tr$ron. rs tmvidcd for by Scctiotr :1700 ol Ih.
<br />btxtr Codc. for lhc lcdnrunc€ oflne wolk for *htn lhc !qr.i n issu.d
<br />I h.vc rnd will rri rii e.rk.rr.o lrrsdi,trr i'Nur i... r\ r.qu tun h!Sdi( l7lr1).fthc l-$orCodc. forlhc pcrlbnnancc ol
<br />"kisu B'r.dcJ Myrn'k.'.',rmncisrr,n.n.ur.trr..ra'.r rnlrtl(_) run..rdc
<br />tr,.,rvt \-1--Y,,ti!y
<br />S
<br />N,,,,r,., q \Aqq O-)-
<br />-lccniiyrhrr
<br />inrfu lxrfornuEcolrhc work lbrs'hich rhis pcnnir t i\\ucd.l shrllnor rn oymyn rv,n i'i rfy n'!in.r
<br />s, rs t,lf,&m \utjc.i t, rhc work.r\ .o'npcn\arn)n Lq\ ofCrlif ir. r rl ll.(rlc rhdr if l nn,uld rrNnr subrcr r, ll..
<br />Norkc^ .onFn\rrion pmvi\ion\ofS..rion17fi)ofrhc btinCdh.I nrll lonhsirh.onltlly!irhrlk,rI'rovnbn\
<br />WARNINC: rillrc lo sccurc workcr' conrposlrn,n covcosc i\ utrhvrul. rnd shrll \uhJlci Ln. lploitr I' d r lp, dlric\ rtrd
<br />civil ftrcs rp k, om hundrd rhou\rnd d.llan ($llx). X)). i',,trldirn,n h rh. ro{ uf.onD.n\nrii , dMuScs rs |novnl.d turlh.{:ry4tfl'
<br />DECI.AM.IIIIN
<br />I hcrchyur'ltmundcrlcnrhyofpcrjurythut I a lien{d undcr nmvision oiChlplcr 9(couJrn.ira wirlr Sfrtbn
<br />of th. Ausincssrtrd Pmicssiors Codc.ond my liccn\. is ir rull frrcc dft cfL.r
<br />w' qs 6R\'{3
<br />to L1 *
<br />CONIiIBIJ(:III)NIINIINC.&CI'NI:I
<br />t hcEhy !fim undq Fntrllyol'rrjury rhal lhc,c ir a con(ruc1ioD h lnsarcncyforrhcptrron,utucorrhcsorkntrqhichrhnpcnnirn
<br />isucl (sa..1097. civ. c ).
<br />IIITLII)IIILDECI.IAAUON
<br />I ltrcny rhtN tr M.r &nrlry oitcrury.trc olrhc r.lk,wir! dc.lirih.ns:
<br />Dcnx,lirion Pcnnir\ Ash.qo\ Norili.nLoi Fcdcr.lRcluhrhis (Tirlr 10. Pan6r
<br />Rc!uircd Lrnrr or Ndifi .dior
<br />Ir.ni!rh rlr I.dcrrl rululr nnr\ ng&lnrl rnf,io\ ntr* lJc turnmli.nhlc k,lhislmlccr
<br />I(difyrlu Ihrvrrcadrhnrmli.dn d irrcrh rhrrtxrriff dn{,\(orccr I !$Lrb(r\rll }irhnllCiryxtr,lCounry
<br />ordi'udcG. dSrarclr*\rclar'n!t,huildi'rg.on{tu.rtrtr,.r'ldhtrchtrurhonTcrqr.\crhrtcsoilhi\CnyrndCounlyroc cr !!.nltE
<br />or., lOkff:::ffi Vrrza,llt€?
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenUlnsulation
<br />Bqof Sheathing 7-/9tC ,/( - 7c a ' 44a,A
<br />Shear Wall
<br />Framin s
<br />lnsu lation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />!!esonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Qeputy Final Report
<br />En gineer Final Report
<br />Flood Zone Certif .
<br />----tFINALtol'>Lt r(1 -"'lodtAq a12Z-/
<br />Certiticate of Occu pancy t rTU n v
<br />Notes , Remarks, Elc.
<br />Set Backs
<br />--T------
<br />L.ndcr's Addrcss
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