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BUILDING- INSPECTOR RECOBD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER AUILDER DELCARATION
<br />I hcrcby .lrtm ulldcr ncnalry,)r pcljury rhlr I m ercmnr rDn rhc ConkrkF L'ccn* hw rDr rhc6llowlrr rc.Ln (Scc.ro.lr.5
<br />Blnncss Url Pltson Cdlc): Ah, C y or G,unty wh'ch equircs ! pcnrur to uonslrucl. alicr. impfuvc. J.nrl$h or rcJDnny
<br />nfldurc. pror r) s n\u.ncc..ko rcquEs lhc applic. n)rn'.[ Frnrit lo ik a risn d nicmnr rhar h..r shc is lienql NN,nl
<br />n, rlr Fovntr,nr .! rt Contartr'\ l-'c.n\cJ llw ((:harr.r 9, Cornrn in! w h Sc.lion 7Il) of Divti,n .l of rhc a!'ms and.
<br />Pn,lc\sn,ni Co'lc)orrhar h.orrhc scrcnrtr thcrckoNMd rhcbisn for lhc allc-lcd c\cnrprnrn. Anyvn,btn,nofSdion70]1.5by ny
<br />ifl'l'.rnr tu r lxr nnr nrbJcchtlr lppli.anr r{' a.ivilpcnilryoinot morertun lilc hunJrcd dollds ($50o)
<br />I, as owncrolthc tn'rcny. or my cmtloyccs wirh w4cs rs rhcn $h con\p.nqrion. will 'lo thc wo* drl lh. sretu is nor
<br />mrcnl.J or olfcftn ntr eL (Se.7044, aunm$ and Pn'h$i lns Co,lc: thc Conra.bii Liccnsc kw docs nol E ply b d ownd of
<br />rhc pn,Fny wt$ brius or unlR,ss rlf,srn, ml wh) &f,s such ql himscllorhc^.lfor(boughhisD!hcrowncmployc.s,
<br />t$viJ.d rhar suLh impmvcmnIs e nn hleolcd or olLrcd 16r ek ll hoftKr, lh. l)uiLiin8 or in{Nvcrni n s'llj *ilnin nnc y(e
<br />ol $m0lcrbn. rhc Owrcr BuiU( will lEr 'tr hunl.n .f F,vins ln.r h. orh. Jrl ftn ho,ll or ntnw lh. pnTsly for rhc nlqnE of
<br />-1.
<br />N oetr$ or rhc |]n,p.n y, !N cxcl$rcly .onrrdctins w( [ necn{J .onrrr.t'c b on{tucr rlr ptujccr (sa ?0n, nnsuEs
<br />!d Pmlssion G,,lc: th. Contacktr's Lir.is.l-rw !t&\ norrpply b dn owncr tl !'r,pcrry who huilJ\ or imldv.s rhcrcon.
<br />mJ wlD tunkd.h ,dr !u.h pn+ds wilh r Conln(n,rl, h.nsctl purutrnr h rh. c.nkac(tr's Lmn* tiw)
<br />_I rnt.xcnpr unJcr s&rioo ,B & P.C. t)rrhistur$n
<br />lvoxtrEBs_coll[Ers .r!aNIrEtf,tnallll!
<br />I hcrchy rllmr utrdcr ncDllryol Nriury.rc ol rhc hll()wu,s 'lc_lf,rurn,n\
<br />Ih,vc{ wlll minrain ! C:cn i6c.rc ., clrrnr b Selll trsurc trr work n- .on{.n\nrinl as lmviled ntr by Sarbn .l70.J or rhc
<br />Iior Cclc, for rhc p.nnmrkc of rhc worl( lor wlEh lhc |rrm is ssucd
<br />I hrv. lnd rill mrint.ir workcN oompcnieri.n insuranc., a$ rcqoircJ by S..hon l?00 of lh. ljtor C{xic. for rtc t rldr@ of
<br />rhc wo* tu which rhis Fdir lr L$ucJ. My *01116- c$nF.sario. iNumc. cmar !i plicy numb.r e:
<br />cu*, I ;;'c7t Q./
<br />L-)-u
<br />_l ccdfyrltr n, rhc llcrloinutrccolthc work Irx wh*hlhrs p.!n is nn'c .l shru norcmlk,y anya.hotr in My matrncr
<br />n) stohcd,m suhid k' rhc *r)rkcr' com p.nsxxon h*\olcrlit)roh. atul,!rcc rhrr,l I should b.com nrhjc.r nrrlE
<br />wo cr( conpcnulon 0ovrions ol S(rion .l700 oI rhc Lnhtr Cdtlc. I \hxll n'dfiwirh conrnly wirh rlDs lrnrvision\
<br />WARNINGT Frilur t, rLrur p.rkcs'u.nrEnslri()n lr)vcritc ir unlnwtul- &l lhrll nrbjd h mtloycr t) c minrlpculri\ an,l
<br />.iv,l lrn.s up lo otrc hu.drcd lhousm'l ,lollrs ($l IIO). rn rnJrri,,n h rh. ro{ nl .ompcnsllrnr, d.mr8$ as pnrvid.n lff rh.
<br />sclrnn, 10?6 lflf,rixtr(0lc inr.rn rn,l .a4PJ->4
<br />DU( 1,,\&\Tl()N
<br />I hctoby r, riro uftlcr pcnrhy of r.rjky rhI I an, lic.id ! J.r povr\nn of Ch{'rcr g (.onrmnci.g *irh S\.'rx,n 7UJ0) of D,vision .l
<br />ol rhc Bu\incs !.'l ProftsionsCoJc. aJrl hyliccnt i\ inluu n)ruca clL(r.
<br />, a\1
<br />co!$allIloNrgNuDc-4liEN(I
<br />I hcEhy rlttn trn'lcr pctrtrltyol pcrjury rhi rh.rc tr a (onddrrtr,n lcnJsg rgctrcy inr rh. t'.dinnan.c ol lhc work lnr rhth rhr I{mnr '{a\u.d lsc( 1097. Crv C ).
<br />ATTLICANT!&ILAEAIION
<br />I h.rcby allm undcr n nalr, of F jlry onc or rhc lnlb*ins ,iftLn bnq
<br />ocnbl ion P$nnts- sb.stos Nolficalion Federal Re3ul io"slTnb40, Pd6)
<br />Rcquftd ta(cr ot Notifiorhn
<br />_l cennirhrr rh. tcJ.gl (Sularions rc8ddin8 dshcnox rcn$vJ *c Nr.r,p[cahlc k' nrn 0liar
<br />y rlu I hntc rcad rhis eplicarbn a}l lllrc lhli rhc !h.vc innrrurb! is corrt I r8rft b comply qilh all Cily an,.l Counly
<br />.c Md Shr.L.wsrchrnrg bbuil'lir8 con{rurri,,,, 3rrl h.rchy ihrft r.t(\ctrhhv.s otrllr C yMJ(n'nryn,cnrcruB'nrhc
<br />!t!)v. nf,nr( cJ F,Ndy lnr n\>>
<br />D4
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation / t
<br />Roof Sheathins // ( /1 ?D2O F/d{ugq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif . t
<br />4 I
<br />Ii L'FINAL t/lqlA$ f t4twuY
<br />Certilic o n
<br />Notes c
<br />{t t
<br />c"Lr.yr,.o",, - ?o &o5 7?
<br />".p*.,
<br />knJ.''( ,lJ.s _
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