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BUILDING. INSPECTOR RECORO
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNI:R DT]It;DER DI]I,CARA'tION
<br />I hcrchy rflirnr undcr rcnrlry ol pcriury rld Lo.x.mr,r ln,m rhc C:(n rd.ro6 Lkcn{c Los r(, ihc r.ll,,qng rc.sotr (scc70lr5
<br />llNi'rcs rnd P.or'c\\i,,n Codc): ny Ciry or Counry whrh Ntuircs r rBrnil h con{n,.r, !lr.t, inPn)vc. dc nlkh or rcl'ln ont
<br />{ru.rur.. t)rior b (r tsurtrcc. {ho rcquircs thc olplicanl itr sucir pcirni n, filc r siercd inrcnf,trr rhot hcor shc i\ liccn\.d Por\uanr
<br />k, rhc tn,vtn,ff olrhc Contacrofs Ll.cn*d tjw (Ch.nrcr c, Co.nnrrcin8 Nirh S.crioi ?000 of Dirisnn! 3 .llhc Bu\nt$ 3nd
<br />Pmtu*nNC.dc)orrhdh.orrhchcrcnDllhcrcfromnndlhct)|shiurhcrllcgcd.x.nprnnr.Anyvnniln,n.fSdtDT0.rl5bysni
<br />iftli.0nrfor r pcnnir subjcch lhc ryplicanr ro rcililncnrliyorn.r mftdDn firc huMrcndollu^ (S50o)
<br />I. ds osn$ofthc |'o[lc y,ornrycnDl('yccswilhuascs!slhcirv,lccotr]pltr{riotr.willdolhcwon(andlh.idrhi<iii
<br />irrcuL\l or oflcrcd lor slc (Sm 70:1.4, arsim\s dnd Prola$ionr C.d.: Thc (bnlr.dof! l-iccnsc h* docs nor npplt ro an osnc..l'
<br />rhcnmFny *ho huilds.r rlpmus rlltren- aJld 'h. dfts such vork hinNlf or h.r\clf.r Ihnugh hk or hcr osn cnfloyccs.
<br />prt,lidcd rhrr such imrdrm.rs m d dcrxH o oficrud titr sh ll lFscrr. rhc lrnikling d nrv,mrlmd G $kl *irhin "nc )tr
<br />olon{lcliotr.lhc owncr Buii:lcr wiu h!!c rrf, burdcn.r pr,lins rhd h..r rhc dil,rr huilti or ir!!,rove rhc pmFny litr rhc purlb* nf
<br />-1.
<br />owncrol'rhc rn,p.dy. rdcx.lu\ivcly.ontn.rilg wirh li.cn{d coMu.r.6ro ondn'cr rhc l)rojd (Scc.704,t. Bu'inc$
<br />nat Prsfs{fn Codc lhcConrrurors l.iccn\c l-rw doc\ nor!!plyrn rnoqnd orrron y who huildsor imtrcv6 rhcrcotr,
<br />rnd who conrrich rff su.h ln)jcch w h,Co.t.crods) licctrsd puFuid lo rhc G)ntdcr(tr1 Li.cnsc tiw)
<br />;:*:"-,u.il;""w"'";L-. l<-l tv
<br />t!!.)B.tix8lt-Q!!!Irs -l!aNDtlL StrUAN
<br />I hcrchy rflli,hrnd.r lf,nilrr_ uf pcrjury onc oflhc fdlowi.3 dcchririons
<br />I hrvc tut *illDrintrifl{Ccrrili.rrcolCotrscnrh Scllrln\urc ior *.rkcrf .oqrnurion, ,r providcd ln hy sd.rhn l71x) oi rlE
<br />lit'{tr Codc- i(n rhc pcrturnDn.c orrh. qolk lor whi.h rhc pcrnrir h h$'cd
<br />-lhrvcandnillm0inraifll,or[cn.o'npcnsdbnin\nrrncc,a\dpirudbysccrion3?00ollhclihorCodc.rrtrthcnrfoflmnccofrhc woli lor *hich lhn llcrmir is isu.d Mywork.^ con1l)tffdion insur0n.ccarict d Policy numl,cr sc
<br />Poli.y N!,nh.r-
<br />l(o'rittrhrri'rrhcnlrrorru.c,nrhcsu'ltur\hi.hrhi\Nnnirl\n{rd.I\hrlltr.icr oyI ry tx^or i'rrny nlnncr
<br />vr rsr, tr,conr hjrd n'rhc trorkcr\ dnntrisrro hwsui (rlilonnr. ipr.cihrl ii l \houltl h..omc \rh]{-.r ri rhc
<br />so'k.rr c.nr|xnsnioit,io!lsi(,i\ofSc.ri( 17{X).1Ihc l.rltr Chdc.litll. hnh*irh comfly s irh rho{ t)tr i\ iur\
<br />WARNINC: Fiilurc n, *.urc sork rs c.nrpcns
<br />.ivil li,r! up b oN huftlrcd thou\nnd dollar (1
<br />is utrlx*rnl. ud shnll {rh)Nr n.mDl,,ycr r{i c' lidrl n.drhe! md
<br />iddir on h rhc con .l co rtictr{rlior. (hmrgr\ r\ tro\nlc li{ rhc")riil 4"+llL(
<br />I hcrcby aftunr undcr lcnrlrroipcrjuryrhar I d liccns.i u.d.r ph!i\i.n olChrptcr 9lor.rEking Rirh S.cri(,n TiXXJ) oiDivilion.r
<br />or rhc Busi'rsnnd PolcssionsC.dc. ad nrr liccns n in rtrllfir.c md trsr
<br />c0Nsrauer0Nt!:Nl2lNti-&clNll
<br />I hcrcby slfinnnl'dcr t'ctrrlly ot rrjury lhal rhc.c is ! on{ruciion lendi',s rtcN.^y lor rirc Pcrrirm$cc olthc *ork r(t rhi.h rin Pcnnir n
<br />i\sx.d is.c 1097. Civ C ).
<br />APILIIANLIIECI,AAA.IION
<br />I lrrny trmuM.r r.nnlly oflujltry onc oI lhe hllo*inr dcchrlrion\l
<br />Dcnrlirion Pfmirs Arhc{os Nor,fi.0rion Itdcrnl Rcauhtions (lirlc lO. Pd6r
<br />_R.quir.d trii.r ol Norifi carbn
<br />-lccnifyrhar
<br />rhc lcdc.dl rcguldribns r.Edding asb(dosrcmoval.rc mr $rliclhk ro rhis phj..r.
<br />-l
<br />ccnify ih,r I h,k rcad rhn rlplicrtio..tu slntc lhol lhc alnve inaomrioo ii.oftNr l,!reloconqrlytrilhallCiir,.dCounry
<br />.din!rcs snd Sr c tiws rurin8 ro huildinS coBtruclior ond ncrchy "lrhoritc r.pE\cnr,riv.r ofrnt City tnd Colnry'n.cnler ur{n rrr^^*,i-i^"i-^i,.i"//qi) u.^ a Le Daq ,tpf4
<br />P.mil* rm. rDrlnlr: ,z
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsu lation
<br />Roof Sheathing "7 -L\ -L(flrTb)
<br />Shear Wall
<br />Framing
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />tl
<br />FINAL /0/9//k a U2,r7Y b>--'
<br />Certilicate of Occupancy ' / /
<br />Notes, Remarks, Elc
<br />Forms/Steel/Holdowns
<br />Pool Fence
<br />Flood Zone Certif .
<br />,Xz,J
<br />tt
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