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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER AUII,T'F]R DELCARATX)N
<br />I lErcny d tn u.ncr penalry,,1p.rjury rtu I {m .rcmni ft,n rh. conkd.lr)^' l-kn\c tjw l[ rhc lollnwin3 rcas'n (Scc ?011.5
<br />Btrri'r\s ann Pioirsri,)n C(xl.) Any Ciry or CDUnry wh'ch rcluircr r l.nnir k' .ondru!|. llrcr. imnrove. 'lcmlth or rclltr Mtr
<br />Nru.rurc, priy b n\ FsuMcc. !h. rcqums rhc .pphi ntr $.h l,cmir t, lllc a \i8ncJ drrcftlr rhi h. or rh. s hcn{d NEUinr
<br />b rhr pn,vlrn)i\ ol rh. Co.racroas L,ccn{d ljw (Chl|}rcr 9, Comnrking }'ilh S..iion 7(XX) oi l)ivisnrn .l ol rhc Burincss an:
<br />ItoltsbnsO'dc)o!rhrrlf,orshckckn,rrrlrtulioman'lrhchan\t,rrhcrllc$.dcxcnlhon.Anyvi'nrlm.lsccri.nr0ll5hyotri
<br />ll)fh turrrrmlt $rhjccrlhc a,,pli.inr b iorvilncnllryolnornrEth rrve hun'lrc'lJollarsl$500)
<br />_1. r\ own r.lrlr pn'Fny. {n n,t cndoyccs $irh q4cs r\ rh.r $lc rontltn\rri,nr, vrlld. thc u* rf,l ih. nn(uc il nor
<br />irfctulcd .r olicrcd tu s c ISR.T(X4. Susnrs ind frntsions Co c IhcConrr&Ln r l.ictnsc liwJoc\ iDr {!ly h r wncrol
<br />rhc nnrFny wh, hu'U\ o n{ft)vG drdx, iuxl wh) !l$r {r[ unt h'nN.lldr hcisclfor lhDueh hs or h.! o*ncnnn,yccs.
<br />pnv c'l rhrr su.h ,ml'xntnrnh m En inr. ctl or.iirc(l li). s,k ll. lxN{kr rh. huiUiry or inDm\rmnr t wilJ *ith'. dnc ttr
<br />_1. 1\.wncr ol r,f, flrt v.. .xclLNivclyernrnd gwirlrli(n\dl. trkr.r,trcI..on{ocrtlrflicer(scc 7044, Btr\u,.s
<br />,trd hnsruConc: IhcConrrn i{tr s l.rccnsc l,iw'l.es n r rmlyr, anowncrol IrcNdywho hu,ld\ {r,nlrrv.s rh.rcon.
<br />inJ $ho (onrturk ntr surh pn,FB wirh a Conra(,(s) lkri*'l tluNnnr u rhc Cin r&r,tr's LBnsc l-a*)
<br />_I3nr.xchtru'il.rS.crrn, .R.&P.C n{rhsr.Nnr
<br />!voBEeB5.:q!a!!E!l4rox
<br />DEeta8/lllo!
<br />I ltcr$ynlnrnrtrnJc, lt lryolncrlul]i.trco,rhcl'rl')wnr!dcrlirrli,rN
<br />_I hrvc fil wrll nrohir r Ccnfcdt ol C.hcnr b Scll lnqtrc li)r w.rk( r .onrpc.sarin,. 3s lloviJci li,r hyS.cri{ l7ul.frh.
<br />trt{n Crxic.lnr lhc pcnnrnanc. ofrhc wo& ld qhi.h ihc t'.iinir N L\srJ
<br />I hivc aml willnnirrain workcrr ronln.n\ari('n in\urrtr.c. x\ rcqon.J hyS.(i(tn 17(X)nl llr kh.rC( c.lorlhcpcrlirmntrccol
<br />llt *ork nn whi.[ rhn pcnni n iM'1. My rr ronrn n\rri,, ninhnrcrdil.r d lnry trutr$crd.
<br />1lale -uh
<br />(;c1 ol ToLa
<br />Val.cnily rhlr ilr rlE noln!,snrcolrlr work tur whi(h rhi! l.rn i\ i{tr.d.I shll
<br />v, a\h h.co r {rhjc(r brlr work.^ ..mpcnu'on lxwsoiCrlilniiu, arlitrccthil il lslxru hc..nr suhjccr n,rhc
<br />wo&ci rnnllrnsr'on po!,\n'n: .t SLari'n lr00 .l rhc trlir Ciilc, I +i11. tunhwirh conrnly wrrI rh,r |x)!i\(nn
<br />WARNIN(i l.aiiu.c b r.urc vx[cr d,hr.nqrion corc !c '\ uiliqlul. rtrd $rU suhjc( ar cnrdoycr [, (ri'ninalt mltic\ mn
<br />.r'l lnr.\ rt ni rDc l,trnnr.J rhou\rnJ doLl,trs I 1l0o.(xxr). m klJr(nnr k) ittr .oi.l (1 )nrpcns(lior. ,l Dlcs is pn,vd.,l nn r[c .
<br />'nc.
<br />u crc( x'kl r otrry\lcc\
<br />I o Zo
<br />' DF€LARATION
<br />I hcrchy.rit unlcr rn.llyor nciury llur I am lienEl un,l.r p!)!tirn ol Chdpr& 9 (.Dmncncine wirh Sculi,n ruo) otDivhi,)n.1
<br />or rhc Busincs ,nd Pftrtrsons Cod., and my li.cns n in tull n&! o,l.fiirr
<br />r,,..",.,,^C4 I or"(o o
<br />L,oza
<br />Y.9 a,()1
<br />I hcEhy at lirm ro't.r Fndry .t p.irtrhd rhcr. t,onifldrr h lmg alcE_y fq lhc pcrli,man.. ofrhc wor* for
<br />t\uen (Scc.,r09?, (:i! C.).
<br />APILICANT DFCT,ARATION
<br />I hcntyallimunlcr p.n.lry ofFrjury otu ofrhc fdlowinl d(larar ns:
<br />Dcnnniri,,n PcnnrlAstrn.s Noriiirarion FcJcBl Rctuhxonr (T lc.l0. P,n6)
<br />_Rcqtri'c'l l.rr.r ot Norillcrri'n
<br />I rcdnylh.r rh. tcJcnlrcetrl.rtr)Ds rredding rsbcslos rcmovil!rc nor qrpliul,lc t' rhN l,tuj.cr
<br />_l .!i ily (Br I ll]v. ftd rhn rpplHr'oh lrl drrc rhrr rh. rlnv. nrturmrr Nn is .orrc.l I!-!8.nr..mplyw htrllCiryr Coonry
<br />,)rdnrn..s an'i Srrrc Lrw!tuh[i',9 k,hr,l'lr
<br />ljhr|m
<br />,{ornn,rMt hr n\rri .1
<br />Applic$nl o. Arenl Sisn.hrR o
<br />Set Backs
<br />FormsiSteel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsulalion A\
<br />Roof Sheathinq /*6-&o xwJn P,tt-' LEFr
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<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 />Engineer Final Report
<br />Flood Zone Certil.
<br />A
<br />FINAL l-Ll'7o
<br />Certilicate ot Occupancy
<br />Notes, Remarks, Etc.
<br />$Lt ".Qv fryp-
<br />,[I\ ,\:T.L
<br />Lcnlc.r A.Llrcs:
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