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BUILDING. INSPECTOR RECORD
<br />()t!NuR Btr[.t)liR Dut,( ;tR/\ I]oN
<br />I lrcrchy alrirm nn,lcr pcnrlr, ol pcrjury rhlr I m.r.mpr tnrm rhc ConrlcbF l-,en{ Lrq rot tlrc ltlt,wins r.3s, (SN.?orl 5
<br />Bunn.ss $d Pn'lcss.tr Cn,e): An, C y or county whEh rqlliEs a Fmd t. .onsrrucr- alr.r' ml]n)vc. dcmoltt or rplr Mv.
<br />drucrur., prior lo ilr h\uanc., dho rcrtuncs lhc amlicanr l r \uch Fnnl l(' tilc a sisn.d {arcmnl drlll lro! \hc n li.c.scd pur{'ut /
<br />t' rhc ln,vrrnr of rh. Conrra&tr s l-ic.nscJ tiw (Chal)lcr I, ConnttuinB wnh Sdion 7mO oi Divrnnr .1 oi r[. Ansinc\i dd
<br />Pe,tassions Codc) or rh3r h. or shc ircicnpr lhcrclrom 3nJ rhe hrii\ t,t rhc rllc8cdcr.mltdn. Anv vNldiu ofS&rFn 7011.5 bv.nv
<br />lppliranrtura!.mnsuhjculsthcllolicanrk)rr,!,ltctrillyrtnolmorcrh,nrlvchundrcJdollar(5500)
<br />L as owncr o! rhc rn,lrny, or my cmnlorcs *irh wr3.r ar rhcir srle conDcntr irm. ulld. lhc w(tl ud rn { rwtrnoi
<br />mlcnJc! droiatuJ ntr sh lse...7144, Bu\i,,c* MJ Pr.fcssbns Cdc lh.Conka.(tr'sLrccnsctiwdo.snotlPllvloanowncrof
<br />rhctn)Fny wl$ ttril.ls or mptuws rhcNn. lri *lr d,4s seh wo'lt himsclfrr hcr*lfor rhough hR or hcr own cnlloy.cs
<br />proldcJ rhxr such inoovcrcnh m nor inrcd.i or olfcr.d tur sdh. lt hv.vcr, rh. huiUmg or ,ryrewmnr is $! wnhln onc )er
<br />old,nrrlcr n. rlr Owhcr aurLlcr will lEvc ihc hurtLn of povin3 rhd h. or shc Jil rt{ hu ,J .! mlmvc rh. P,op.iy fdr rh. Pu.rire ol
<br />l, rs owncr of rhc p 'Fny. m .klusircly .ootraclns wirh INnr.J .onkn 106 b conntud rh. tn)jccl (S&. 7il44 Bn\Dc$
<br />ani h i:siJn Codc: Thc Contr!.ttr s t-iccns. Lrw d.cs nor ltPly x, er own* ol !rupcny wlo huild\ ot ,mnrurcs lhcrcon
<br />.nd who.onrn.hri,r\!ch,,n+ck*ilhaOrnrract'(rliccn(iNnu{nrk}rhcCintack \ Lacnsc L.w).
<br />I rmc\cnr u,rJcrSc.r(
<br />WORKERS' CONTPENSATION
<br />IECLAEI{IIAN
<br />I h.rchy rlfim !.Jer F.alry or rajury om of lhc l',)Uowiry deLiati,ns:
<br />-l
<br />hnvc.nd will mainrain a ccdfcarc olconscnl ro Sclf-ln{r. ror wtrkcn 0oml.ns,rion. ds lrsvincd tbr brS.cbn l?00 oflhc
<br />Lho'Fud.. rorrh pcflom." ulrt u.* hrwhkhrh.pcmrrh i.\ucJ
<br />./t hJ". and srllmrmr,m wurrcF (,imncnsdr,n
<br />'n\uronc., a\ rcquiRl hySdcrion.1700oflhc L.borG',ie, ror thc !E lomane of
<br />rhtFrmir b NsucJ Myworksr lnnPcNnr (xn.r J tin(v rumh.r m
<br />l\vvt t.vllan C-'tn
<br />""*" --NLSDqlo 0lZ It 7-O
<br />l..nityrhar 'nrhcltdnrnrncc lrhcworkturwhrhrhislcrnririsi\sucJ.InrrllnolcmfloyanyPc^on anv manncr
<br />n, s b h.com {ftFcr l,' rhc u'a($ conrP.n\arion Uwr of Cllilnmil anJ r8R rh rlIsh ndh.d,k{b]cdbrhc
<br />{orkc^ coniFn\ otr ln,vsion\ ol S.cr hn l7moilhc LltrtrColc.I nBll.lonhw [$n]plywirh
<br />WARNTNC: l:{ilurc t, scNr. workcs'conlransdi(r.ov.E3c i\ utrldwtul 4tu1 "hrll Nrlrj(r M loycr n,.flnrsil l]cDtrllFs r
<br />c il hncs ut lo onc [trft]Fi rhdtrsrnd dollus (Sl Jrmscs as F)vi,lcJ l'or rhc
<br />s..hn 10?6 ol th. I iitr Ciil.. inrcrcn .nd ll
<br />oLo
<br />I h.tohvafnnrlrktcr|tnilryol O.rjuryrhd I ir [{tsl un,]cr |l)vn(ri .l ( hnnrc! I (.omntncnr! q hSccriir?fD)rfOlvstnr '1
<br />or rh. Bulin s d Pmfc$ions Cotlc. ,,rt my lf,cns ir h tull lorE ,!rl cner)o qvj 1sto
<br />1 vr/o o A
<br />CONSTRUCTION I,ENDING ACENCY
<br />I hcrchy atuh und$ !.nallyolFrjury rhd rh.rc N a connruolnrn bn'jine ascncy ri,lhc Pcrlnrmucc orrhc work for whth rhis p.tmil Ls
<br />iss'cd (Se 1097. C'v. c l.
<br />ATTLICANT I)ECLAR lION
<br />I hcNl'y ntim tn'lrr p.nrlry of p.rjury ooc olthc fo&,wmP Jc.lmln F:
<br />Dcm.l ion Pcrmirr Asb.sos Notrli.!lion lr*lcrrl R.ttrlalotrs ( lrrlc 40. tun6)
<br />utr d lr(crol Nohhcinor
<br />.dllly rhrl lhc li lcrrl r.ttrldorN rt!minr8 3\hc(os r.ntrrltc tr.r trfll
<br />lc.niiyrhar lh2v.r.rdrhr.pr)lirali,)n ldrerhr hc.bvcmli).matn,nir rc.r I4re t'ohply wirh all C yaftl Counry
<br />. inik.\rnn Srnc l-rqrrl[men]\a rrivcsol rh,\C yrnd C.unryt'.trrcr tr|x{rh.
<br />rtrn. n[nri{m.'l p ,p.ny ntr i I nlzoto
<br />COMMENTSSITE.WORK DATE ID/SIG.
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVlnsulation
<br />Rool Sheathino
<br />Shear Wall
<br />Framinq
<br />lns u lation/ Energ y
<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 />Enqineer Final Report
<br />tJ Ai -tFlood Zone Certif .-fftMqvc{+flltlatlf +tr{es)r3I
<br />-d-oFINALq.{ r42o
<br />Certilicate ot Occupancy
<br />Notes, Remarks, Etc.
<br />4
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<br />trn ici s Ad.lF$:
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