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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS owNoR !u ll,Dt:t DDLCA F,A t toN
<br />I h.Bby rlfi.m undc. p.nllry of p.rlury rhot I am.rcmpr fom (hc conr*ros' Lk.ns lrw to.ltE followhg Easo (56.7011.5
<br />Busin.sr and Proltsion C.de)r Any Cty o. C'oun(y which Equnes 0 pcmit ro c.nnru.r, alrd, i'nprov., d.mlth .r qMn rny
<br />nrudurc, riq b its issurru., also Equircs lh. appliljrlt rbr such p.mir to fit r :tEd $ .tu rha h. or sh. is ti..n*n puruini
<br />16 rhc Fovirbns of tlf, Cont*ioas l-ien$d llw (Chaptd 9, Commcftihg with Sccib. TUt) orDivhio! I otrhc Busircis ood
<br />Proltsionr Cod.) or rhat he or rhe ir creopr th.r.lionr and rh. bxrir for dr dLg.d cfthoriotr. Any viol{rion oi S.€rio{ 7031.5 by atry
<br />.pplicrmlii.p.mtrsub.]..rs$.rpplicrnt16icivilF.uhyofnor'm(rhtrfiv.hundrdilolli(($5(l()).
<br />_1,.r .wnn .l rh. pmpcdy, .r my cmFl1y.$ wirh wa3.s ,s rhcn $b c.mp.ns ion, villd. rh. work ard th. $du.c is mi
<br />i.En!.d or olt r.d ro. $L (S4 1)s, Busircs ond PmLrii.nr C.de Thc Conudrol\ Lic.nc Liw dG! Dol opply ro a. owrcr ol
<br />rlEpNntdy wl$ hoilds or inltou rheE)n. ud wlD d(B such a)rt hinN.llor h.r$llorrhdr8h his or h.r oqn.frployer,
<br />!tuidcd rh.r such inpmE.rnh m mr i .d.d .r .jftftn Ior 3.L. Il, h.*.vci ltr hliuin3 .. irq'n€mnr ir e! wnhin om )re
<br />ofconrpLri4 rhcOw,rrBuiLLr will hrw rh. bud.n of povi',9 d* IEoish. did ior boilil o. nrpoE rl* pmFn, fnr EtuQo*ot
<br />L d.ow,E ofrhe Dmp.(y. !m.r.lusiv.ly.ont{.rin! wnh li.cnsJ &lkddoB (o.otr{tocr rh. poj*r lS(.7Or4. Busincs
<br />a'rl t irftssir Code, l he ConrBcrol! LicdNe uw doe! rot rnlly ro anowndr 01|noPtny who hnilds or inpolcs rh.r4n.
<br />and wtr) c norh Lr lch prFh wih a oraet,(sj lrcdNd pu^ud ro rh. c.ntrcror's Lic.Bc tjw).
<br />I rncrentn utrdcr Secton ,4.&P.C Lrrlrisr.rur
<br />!I]IT!AS1Q!!!ITIA:II!)T
<br />IIECLA.B r!O!Ih.rrbyr nn undcr $nahyotpcrjuryotu ol'rh. hli)qin8 l.clrariri
<br />_I h*r &l w'll mDrlr a C.nitloard of cl)ds.nr to s.ll-I'$ore for wo.l.rJ conD.6dion, as pDvi!.d f.r hy S.ction 1?00 of rh.
<br />Ltir code, lor rhc Frrormrcc or rhc solt tor *tich rtE r'.rmi ! i\su.d
<br />I havc lnd vill mainrnin wo*.6 corn. aqon ,sukNr !s EquiEd hy Se.oor l7O0 oi rh. L!ho. Cod., for rh. I'..fo|]rjm of
<br />th! *o* nn *hich rhis pfimir is i$*rl My *0116 sml.Mrion rsrMcc 6nier nl ,olicy .umhs {c,
<br />-l
<br />.cdily rhar in rlE li.rli,mBrc. olrhc eork itr *hich rlris p.rnir is issu.d,I shf,ll nor coploy any l)lr$n in any mankr
<br />ersrobcsmsuhj.crrorhc*ork..ohp.nsrionlaMofcrlilo.rid,ind.Srcrhariflshouldb.!omsubrccrrorlE
<br />worlrJ lump.n\arirn ptulnions of S.criotr l?l)O of 0E Lahor Cod€, I dEll. fonh*nn .tnpl, wirh rlD$ pmvsiotrr.
<br />WAININO: &ilur ro Ecue rorkcL' mmF6arioo covcDgc is unliwtul, rd nBI subl.cr m.nploltr ro dihind Fdlid ind
<br />cilil lircs up 10 oE huorlr.d rhou$nd dollaB (ll(ro.i)($), in 0ddirrn ro rh. cos ol co p.nsdlion, dam8.s ns ptovid.d fo. rh.
<br />Sccrion 1076ofrh.lrt r Co<l., inr.rsi and arromyi f..r.
<br />LI!ENIED.(I)NI&1(1(A
<br />!Eel^8{IIO!
<br />I hcr.byalln'n uf,dcr Ij.nahyolpcrjury rhir I im lic.ns.d under rmyision .l Chdlk 9 i..'nmn.i.g wirh SccrDi Tlxm).rl)ivNini 3
<br />ol rlE nurnc$ md PnnasionlCtxh dl nryliccnlc is tn tull l.rc.uxlclfcc.
<br />Licc@ Cla$i_Liccm. Nomb.t
<br />cQ!$a!clp!j,!!p!!c4D!cI
<br />I h.Eby dltr6 und.r tE'Ehy ofp.rjury rh4 rhd is a oonnnr.rion bndirS !3. y ftx ihc p.rfomN. of th. mlk ior whi.h rhis !,6ni n
<br />kucd (Scc 1097, crv C)
<br />APPLICAMI DECLAR{TION
<br />I tfthy atrm utuldr p.nahy of p.rjury on. ol rh. followirB t ccl0rariotrs
<br />DenDltion Pcmirs-A$c(os Norificarion F.d..ol R.sula'ionl Onk a0, Prn6)
<br />R.aun.! I.tr., of Noif@rio.
<br />-l..nilirhd
<br />rtE f.d.rd reglhlions Eguliry ashe{os r.mvrt ar. n I rpplicahl. e, ihlr pol4i
<br />.d&.nity rhd lhe.mdrhis {plic ion ffil $de thd (h.turion ir.oRr I r8reroconDly wirh dll Ciry lrd Coudy
<br />onliN'r.slrtSrrEllwsrcbiingbtuildiDgcoon .lion a rhoriu. EF*nrariv.! ofrhJCiry lnd Coutrryro.nr.r ut'o. rlE
<br />b-
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Eneroy
<br />Drywall
<br />Ext.i lnt. Lath
<br />Brown Coat
<br />I\,4asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />FINAL Zl I't/20 D,AffiI
<br />Certiticate ot Occupancy
<br />Notes, Remarks, Etc.
<br />Rev. a)8-07-2015
<br />Sublloor/VenVlnsulation
<br />Flood Zone Certif .
<br />Dsl.:
<br />Policy Nunb..r Erpircr:
<br />rlrn. rtrfuxu]J[)|t'rv l,n
<br />,,,.". zf tq/z.o
<br />ifrts
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