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BUILDING. INSPECTOB RECORD
<br />COMMET{TSSITE.WORK DATE OWNER AUTLDER DELCARATION
<br />I h.rhy alarm undcr JEndlyolFljury rfiar I m cx.mnt rom rhc Conl.,croE l-i&n{ hw for thc toln'wins rca$, (Scc 70]ls
<br />Busincs and PFtasi,n Cdlc)r Any Ciry or County *hich Equircs d tfmir l. .onslruul- allcr. inptulc, d.molth or EPan anv
<br />srrurrurc, tBtr b ns i.sudrlT, llw requiEs rb. !0plir r tr such Fmil lr) filc a sisncJ {arctunr rh hc or slE t lic.o{d puNer '
<br />ro rhc l)^rvisn,n\ or rhc Conkctoas Ltcnr'l L,.w lchaflcr L Co.mc.cns wir[ Sccrion 7000 or Divton ] ol rhc R jin'sr rntl
<br />Pdltsid.i C\lc) or lhrl h.orshc i.knyr thcrcfom lnd lhc biss lffrhc alLgcd.kcmpt n. Anyviola(i,'n.fsfrri,n701l.5 bv.nv
<br />lppltranr ,br n lcmrir {ohjek rlr applMnl lo a.irilp.nall}oaoor Nn rh tivc hundEl doll{\ 15500)
<br />-1,.1
<br />owncr ol lhc pmlrny. (tr my cnplott \ wirh waScs r\ rh.r n,lc .,,nlPcnsn,n. s'lld. rlr trifi ml rhc nturw h n.r
<br />hrcfilcJ o, olli,cd n)r sk (sN 7&4. Busrcs in! l\olistr,n\ C, ilc Thc Li,nrr.i! { ! LtrcnE Lru J,r' n'i Jiflv i' an o*rcr or
<br />rhcpn'tcdy qk,builds r impl)v$ rhcR'n. drl *h, d(B {l.n $)d( hinsc ll or hc^.lf or rhDU3h his or icr own cmll,vcci
<br />IJn)liJcJ rhd n(h iDpNrnnh m rn inrcnJcJ or otLrJ tur kt. Il h)Mve. rrr t uiuins or inlhtnrnr N $Lr within ^nc trr
<br />ofco.{krn,6. rlr O*rc! Builder will hf,h rh. bxrJcnol Pn)vm! tharhc or\h. J fr, huiU or in{orc lhc nnBny tur rhc Nllr'* of
<br />L r\owncr., rlErmpcny, rhcxclunv.ly.onk,cluu w h liccnsc.l rotrracroF t,.onstrucllne pn+d (S(.704'1. Busm$
<br />.rrl Pd!:sir CoJc: Th.cotrtr.lr'r l,lucnsc l-rvdoc\ nor aprlyk, downcro, p0Pc ywiobuildsormrProvcsth.r€on.
<br />rn'l qh. onnacl s t)r such pn+ds wnh a GJntrtu(9 lcctrscd pununnl b rhc cdnM.ntr s Li.ctrE uw)
<br />Lrcr.mDr un,lcr Sc n,n
<br />rloBtsE8strorllErt lroN
<br />DA(n-ARATION
<br />IrnrXyol ncrjury dnc olrhc Llk,*'n3 Jc.l*3r(ris:
<br />,Jr!anJ*illminrainx(tnrllcalcolConscnrroSclllnsurcntrwortcs.ompcnsdnrn,ar Pnvidcd lir hv Sccnon lTlll) .f thc
<br />jtuG c, for rhe p<dbll@. of rlt worl( for which ihc 0cm is isru.d
<br />-l
<br />hrvc d wrll trrrnian workcri on,|tnrrrk{ ffurlrEc, as rcquncJ hySccrin' \7U) 1rlE l,rhorC, c nr rhc ncdnrnrn.c ol
<br />rltr *,trk l,tr whrhrh( mmm,s rsu!{ Mt w, lcr'
<br />crn,c, SLl< fr41
<br />?o3o <>-
<br />. dl inthc pcrli)rnun colrhc wd* ntr whahrhis Pctrnil is r\ncJ,I rh.U h.r cmlkly any t€6un inrnv.Enrr
<br />'-.ohq,msul'jecrbrhcworlcN.ompcns{tn,nhwsoic{ntaha,aidaSrccth{riltsholLth.comsuhj.ctlnrhc
<br />workcn c.opcnqriont!,!irir.s olSccrio,lruolrhc LahtrGic,I sh,ll. funhwithom0ly wirh rli,{ tln)vnioN.
<br />IVARNINC: Ira'hE (, *eur. *orkcr
<br />.'v,l ,n,cs uf h trc htr nrc'l rhousrnJ
<br />Scllon 1076 I rh.litu C{ri.. inrcrcn
<br />fi-^ /3- zozo
<br />, L&I;AIIUIONI&ICIQ8' \ ITECLARATIoN
<br />I hcruby d11tr u.,jcr pcnrlly ol Frjury rh Lm lienrd\dcr provision urcha cr9(ommncins urh Selt)n ?OO0l otDiliiion l
<br />ol ihc Busftls dJ Pmrcssn'ns Codc, lri ny lic..sc L\ in tull lirrue lxl cliccr.
<br />3Ytz6r
<br />7-t3 2eLo
<br />I hcahy,llt'n utul.r Fnattyolpcrjuy lhar
<br />sru.d (ss.1097. ci! c ).
<br />('o^sTRUl"TtON t.ENprN(i A(;ENCY,t'./",."^ro{.n rnumg +ctr. y xr rh. rrlrtutrlc Irh.!.'kl, trh(n'hslrm r
<br />APfLICANT DECI ARATION
<br />I ltEby 'ntim ontlfi p.nrhy ol pcrjury onc ol rh. tulk,wre dcclirx( ons
<br />D.mnirion Pcrmih Arh.st.s Nolili..lion Fcdcrll Rcsrl,rion\ (Tnlc40, PM6)
<br />Rcquircd tdrcr ol Nd,rql,,
<br />I cdify th.l ltu fclcral Eilhriors Eeudi.e LrtEnos Emv.l se nn ,rlluhl. ro rhk ImFr.
<br />-l
<br />ccnrfy rh,rt h,vc ad,i rhr amlndDn ad {'rdhrr rhc xhovc inlomron is co@r I a8E to 6mply *irh dl city rnd Countv
<br />or,imu..s.d sr\c !/v\ rch!ns ro hu'ldrn! oniru hr, ol hcEty aurhoriz. r.pr.*hralivcs oI lhis Cn, a8i Cou.ly lo dls uIDn thc
<br />rh,v. nrnti,nk'l Fr0.dy ld FtEcri,
<br />,\ppliLhnt or A/trr Si(."1 a /J zoao
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />SLrbf loor/VenVl nsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulationi Enerqy
<br />Drywall
<br />Exl./lnt. Lath
<br />Brown Coal
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL /-22- 2D wr/o,
<br />Certilicate of Occupancy
<br />Notes, Remarks, Etc
<br />ID/SIG.
<br />Set Backs
<br />.onrpctrsarnnr inluan c crnnr lnd lr,lry nn.,nc! m:
<br />//' /- zo.o
<br />n, inJnkr r) rh. con ol
<br />krdci\ AJJrcs:
<br />-
<br />--T-
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