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BUILDING. INSPECTOR RECORD
<br />SITE.WORK IDiSIG.COMMENTS oWNER B('II-DI]R DIIt,CARA'IIoN
<br />I hcrc$y ainm uftcr p.nllly ol rrjury rl[r I m crcfipr ron rhc C(, ra.r6' Liccrsc Lrw n)r rhc rbllowins rcrvr lscc 7o3l J
<br />Businc$ lrt Prot$n,n Cdc): Any Cily or Counry whi.h rcqutes r pcrnil ro consrrud. q. imrnx?. d.n!,li{h or lcp0n ,iy
<br />{nr.rrtrc. prhr Io ilt isnlncc. r1\. rcqutcs rh. afdicunr lhrNch pcrmir r{, tirc a sili.d srxrcnr(r rh,r h.or dr is li.ctr{d purur
<br />ro rhc pmvhn,trs of lhc Co mctols Li.cnrcd tia (ChrFrcr L Conrnrncirr wirh Scclion 7(x{) oI Divhion.l olrhe Bu\ir.\s and
<br />Prcresions Codc) .r rhlr hcorshc hexcmpr rhcrelionnod rhc 6!\is i,rlhc rllcgcd cxcnprtn' AnyvnnrrinofS..ri,nT0ll.5byni)
<br />rmli.anr roi r !.rmir sxbjc.rs rh. rttlicinr tu r .i!il Fnalrt of nor mft rhu nrc hutrdrcd dollu\ (S5U)).
<br />l.trs.wncrolrhcFor.y,ormycrplotdcswnh*nscsairhcn$b..hp.sdn,willdorlfwork0Jl(lrhcslMruEi\nor
<br />inlcnl.t or oft,cd for slc ( SN.7O44. lrusinc$ atrd Pmltssions Codc lnc ('onrrocrois Liccose l !e docs nor amly h an oqn& or
<br />rh. pn,lEny *ho hoilds or imF)ws rhcmr. dd {ho drs skh uorl hinr€lf.r h.klf oi rhough his.r hcr own cnDloyccs.
<br />pnvidLrl rh8r \nch intPmlcnrnh urc nor i' cndcd .r oficrcd fd sk Il hpcrd. lhc hoildin8 or itr{,Nrmnr is soh wilhin orc ,!u
<br />otconlrlclion. lhc O*rcr Buildc illh!rc Ihc tndcn of 0mviu rlDr tEorslrdil mr huild (r irqrovc rhc ph&ny ror fi. I,u |ncof
<br />)ll *,,"*,",'r,"p,,p..1 n c rcl'^' ! rl! f,,nkr, ins {irh liccnfd conkacri,F t, conntucr rh. p4ccr ( sc. 7(114. sniNs
<br />'/ ti fh,ls\tutrCuJc Thr Cuntrr.l.r\ Ltr!tr)c Luw tlo.\ troi applyb rn.sicr oi Ffl'pcarwho builds or nnfruves rhcrcoo.
<br />rtrd qho conrEd s nn such loj.cr \ wirh ! ConrEdd, lic.n*-d nursurnr r. rhc Conrrtn\ l-iccnsc l iw)
<br />t/u o O o**.
<br />I hcrcby rfl,nnrn,lcr p{Mir! of|xrjtrrJ- oi. ofrhc n,lI
<br />I h r aid willmriotrifl!CcnificarcofConsnr ro Sclt l'Nurclhr worlsi coErrnsa' ion. !\ pr' d.drrtrhySc.rion37(x)oilhc
<br />titxtr (-odc, for lhc pcrr'ornmre oflhc work for *hich rhc !d, n nsucd
<br />I hav. ond will mri.rain workcrs comtl.n$iion insunrc.. $ '.quircd b! sNrion 17m ol rhc L.txtr Codc. hr r hc pcr{o.manc. oa
<br />thc work ror whichrhicp.rmir i\ issmd. My workdC .omp.n\rli.n msunRccmis mdr.licy Nnrbcr !rc:
<br />-ExPies
<br />Xl.cdrl, rh. m rhcFrr,trtunlci,rrhc tritrk ror *hrh rhis pcrdn is is\u.d.I shdll nor cmptoy y p.ro. in nny mlnncr
<br />/e o\h hc(,{r suht (r r,rhcq.rkci\ (onrrn!.'i n hsrorc,lironrir.. dn8Eclh0l il I slwld bccorE suhicr Iorhr
<br />/y 'lr'( c.n'rcnsrriotran\n n,nrsccrii n.lrrUi'frhc L'1...r roJc.ld0ll. r'odhqtrh.on'dy tr hrh.$rn!hi,.n.
<br />\yARNlN(; Irrihtr. tr, {.trrc wo'kc^ ro p!n\ni,n, c.rcrxgr tr tri l. rtrd lhnll sult.l ctr'ploy.r ro lririnnl Fnrkic\ rtrd
<br />.nil rnr\ utr r' .nc hu r.d rhor\rftl rlolrr\ l$lrx).lxxr). iI r rhc.uq orcolnFhs.rion. dami8cs as lrovidcd lor rhc
<br />Scri,n.1076(
<br />"".rV
<br />)lrtu l;'titr(ixlc. i or.{ rn,l rrttrtrcr_ \ li.!
<br />lo nrrr,*"t
<br />I hcrchy ofilnlndcrFn.ltyolpcrjury lhol I nnr liccn{d undcr lrovkion olChapicr I (omnEmins wnh selbn TmorolDivisio.l
<br />of rhc Busircs trnd Pn)fc$ionr Cod.. rl nry lic.n{ i\ in tullf(tr c Md cffLri.
<br />coNsrf,ltcurlNrElLlcENlr
<br />I hcEbyarfirm und.r trMlryofFrjuryfid th.rc h n co.(fl.thn Lodint !8ctrcy iitr lhc |rcrfonnircc oarh. work nr stth rhk pcnnir n
<br />isiu.d (S( l097,Civ C)
<br />AITUIAII.DI,CLAIT )X
<br />I hcrcty lflinn u ndcr Fnnlly ol rcrjury onc oftlE follosing dccl,rorions
<br />l)cmrilion Pcnnils-Asb.stos Norilic.lion FcdcrulRCEUhrn)ns (Tirlc4r. Pan6)
<br />-Rcqutcd
<br />Lcllcr ol NorifEalion
<br />I.r'tl_rthrl rh( fc(lfrrl rclular(,r\ r.!&li'rN r\lri,!\rrninrl c or rlrt 'rrNc t) rhi{ fi.t .r
<br />-^L.n,,'n,, n,'"."n,un,nnu..,
<br />f,nhnr'rc\JnLl \r ( l#\trlnrtr,! r hd
<br />rhrc rn'in c,lnror.ny tnr irntrri, r
<br />rhd rhcih,\c inhrnuri{n, i\.orccr I alrm h comply wirh all Ctry rnd Cuunry
<br />i(nr. rlh.r.nyxurhori/c,+r.\cnrrri\c\ ot rhn C irvrnd C.trnlyrocnrd trtxrrhc
<br />EA
<br />*,,, Vt?/tott
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq
<br />Shear Wall t-ZQ -2-
<br />Framing
<br />lnsu lation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonr v
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />FINAL C'tt- 2,o fE..P l=,
<br />Certificate of Occu pancy
<br />Notes, Remarks, Etc
<br />tA
<br />DATE
<br />-l
<br />adcrcdpr udcr Sr1n,n-.
<br />cMi.r
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<br />L.ndcr. Addrc*:
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<br />appri.sn, or uo' si*m,'Fi+
<br />""-u**.",0n",, ,J6?
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