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BUILDING- INSPECTOR BECORD
<br />COMMENTSSITE-WORK DATE
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsu lation
<br />/az4ff IRoof Sheathino 4 tolw'lw
<br />Shear Wall
<br />Framinq
<br />lnsu lation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputv Final Beport
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />I
<br />>12/l//Y 1nA i*Itt
<br />Certif icate of Occupancy .,Iv ln r',-
<br />Notes, Remarks, Etc
<br />pl
<br />OK, fr 121)
<br />OWNEf, BUIr,DI,II DELCAIATION
<br />I trr.by arinn undcr ri.nrlry or n rury rh$ I d.rcnDr ionl rhc Contr.rors Liccnsc lf,w tur rhe n'lbwirr {'$n (sc' 70115
<br />Irusincs ud Pi(,rcsin Codc) Any citt or Counry *hich rcquir.\ n Fnnir h consrtu.r. arrcr inrProlo dcmolth 'tr rulun dnv
<br />srdcrurc, trid kr irs i\stx.... als. nquircs lhc lppli.mr rur str$ Ennir t,lllc, rrtnc.l slilcnEm rhar h.orshc i\ Ii"nscd lunu{nl
<br />kr rhc p('!isi,,r\ of rhc Cotrrrcrois Lic.n*d tis (Clrprcr L Connncrcirg wirh S..ridn 7t)tro ot Divtion :1 oI rhc Bu\nr\s rnd
<br />ProlcssnrN Codc)nrrhlr hcor\hc iscxcmpr lhcrcaronmd rhcharh lbr lic all.gcd cxcnipri{rn Any violari'n ofS*rion 70:ll 5bv!'v
<br />atlliconr lor aFrmir subjcch Ihc uptlica.d. uciviltcnlllyoinor 'noru
<br />rhrtr livc hundrcd dollrrs 13500)
<br />,. r\ ouncr ol rhd ptuFdy, or nry cnrPbys\ *irh sr8cs as rhcir v,lc ..trrlEtrs0tion. *ill do rrE wor* and rh' $mrw h n
<br />i'nmdcd or ofic!.d ld srlc ( SN.?(N4- Busirrc* Md Pmfcsstuns Codc Thc Conlrucroi s Li..nsc L1r docs nor aPlly lo an o*ns of
<br />rlx F)If,ny whJ builds.. inl,ord rtrm.. lrd who dms stch so* himsclfor hfi*ll or rhn'ugh hk or hcr osn enPloltcs
<br />frevdcn rhar \uch inpturtn.nrs @ ,i, c td or.ficFd lbr {lc ll horcv.'. rh. hxiLling.r impowrrc nstsirhinoR}rtr
<br />;r.ompl,:rion. rhc o$;r Buildcr willMvc rlE tDrdcnorpn,virr8 lhd h. or \hd dil nor buiH or inDmrc rc PNPcnv ror rhc PUrr'{ or
<br />-1.
<br />!sowncrorrh.Ircpcny, amcx.lu\ilclt.ontlcrirrg $irh licci*d .onlrrroF b con(dd rh. I)Iojmr(scc 7Or4. Bn'inr\\
<br />rnd Pnrlassi.n Codc:;ft; Cotrtrclu s Liccnsc t-tw 'locs mr applrro anow.cr oflliPc v*h. buildr or n!!tuvc\ ther'n-
<br />nnd sho oorfldsn, such projcck wirh ! G)nlmdod s) liccnscd Pununl r. rh. C.nrdols Lic.nrc b*).
<br />I rncx.nrfl trndcr scc(iL)
<br />D.re' Oen.r.wonxris'coupns,rrttix
<br />DECI.Af,A.IIIIN
<br />I hccby afilrn undcr lenrh, of Frjury om of lhc follo*ing delnr(n'ns
<br />-l
<br />hsw and will'MinllinaC.din.ar.ofConscnllo Sclllnsurc lor wolkcn .onF.sarion. as l/.lidcd forbvSccrk'n 1.7 rorrhc
<br />t bor Codc. id tt[ p.rrbmm. of th. wo* tot which thc Pedh i! issucd
<br />-lhawmdwillmli
<br />ain workeB compcns ioniosutunc..ns rcquiEd bv selio..UOo otrhc tibor Codc
<br />'or
<br />rh' P'rfornunce or
<br />rhc wort lbr which this ncmir ir isscd. My worksl .onp.ns ion iflruotuc fficr otn policv numh.r ec:
<br />- O P-r t>P-.s pn. ^t I^ < 5VL
<br />2_(.b \-\- ?-(, \ q
<br />1LI.. '1!rhrr 'n
<br />rhc Nrt"rnrxnlc ,rrrhc trnrl rnrshtrhlhisPcflnir is i\srd l shrll nor tmflov,nvFrvnr i'r riv [trmr
<br />o 0st' hfton- \uht .r k, rh. workn comFns riotr hws olCrlilt,nrir. dntl !8rce rhar ifl shoul! t'con* suhi'tl lo rti
<br />workcn dnn ds[ion Imvhbns of S..rio. ]700 ol rlN I rtin C(xlc. I sl'"111. [onh] h mmflv s irh rho* lnlision\
<br />IYARNINC: ii'ilurc k, sccu'e s.rtc6 .onrpcisnrnnr .otrr03c is trnl qful. otr.l shrll subiccr irl ctrrPloFr ro dn nrl ,cnrhics nntl
<br />civil 6n$ up b otrc hundrcd rhorBid dollur 1S100,(X in lddnn ro lhc con ofco.rp.nsoltun. d mScs rs lrovidL{ Lr $c
<br />scdi(r lll?6 otrhc tltn (iic. inrcrc( rnd rr
<br />Dare - \@ - 1-ZqB 1
<br />DEILA8AIIgN
<br />I hcrchy0lnnund(ptn.lryofpcrjuryihd, tr lctrsdunncrPn)!is6n.lChtlrcr9t..nnncncing{irhS"!tunTolxDorl)ivi(htrI
<br />of rhc Busircssrnd Pmfc\sion\ Codc. and dr li.cnsc s in lulllnr..andcllccr.
<br />c-j1-3I
<br />CONSTRII(]TITIN LEND!N(i A(iENCt
<br />I hcrcby.lim u.dcr Fnrllyolpcrju'ylhd lhc'c is,.oNruclion ].ndirl! n8cNy li)r ihc Flfunnlnce ollhc *oll li)' which lhil..ani is
<br />issucd (se :r097,civ. c )
<br />! Addrc\
<br />-
<br />APPLICANT DI'(]t AR\1'ION
<br />lnDuBLr Fnrlr, of pcrjury onc of rh. Llb$ira dc.irlr6.\
<br />Dc'n,lirion PcrnitrAshcdo\Ndifi.dion ltdcrrl Rcgtrlnrions(lirlcJl) PM6)
<br />,l.qutrcd L.rrcr oi Norillori(trr
<br />lccnilyrhrr rhc l.dcrrlrcEul!rn,i\nArdiraashc(o\rcDxrnlrc tr rnPpli. hl. rr rhis Pri!.cr
<br />thdr I h,v. rcad rhis {rli.lrion rt slrlc lhrlrh. fi)vc nriomuri,m ir.omcl.l aE e t,.onrrlv $ilh sll cir, a'd Coutrlv
<br />,nlnxN.\ rtr(l Srn. t.ns\nlri'i! I hxildrnp.on(rucrt,n.,rxih.rcbyanlhorirrrcflcsctrllrivcsofihisCiry{.dGnrnrytocntcrupon
<br />ll)v. nrcnri0nc,lfr,tr y tur
<br />,\pplir.nr or,\!.tr1 Sianaltr u,,., to 2- ?9r8r={2- ',
<br />tal
<br />ID/SIG.
<br />FINAL
<br />llvv,{ lun'a \rt"7 pw
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<br />D,r.' \O--a -\g
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