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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COIi'MENTS .oWNER BUII,DI]R DF]I,CARATION
<br />I h&.byal1lr undcr,.nahy of p.rjry rhd I anr cxctrlpl frJnl rhc Co kr.ttrc Liccn{ lls nn rhc nnl{,wing rry,n (Src70.115
<br />lrusincss and Pr.lcssn,n coac) Art Ciry or Counry qhich tonxncs a lrnnn r, .oniru.r. ax$. nnp,.vc. dcfr'lish or rpf any
<br />(rucru.c. priar n, iIs issurnc.. !l\o rcqurcs rh. {rlicMr r{n \d.h p.nnn ll, filcr lisncd nalcm th hcorsh. ir liccnscd runui r
<br />ro rhc provirnnr\ ofrhc Conkn rofs t-i.cnrd ln* tcluprcr 9. Connncncins with Sccrnrn 7()(D.f Division I oilhc Irrsincs rnl
<br />Pmfcsion\ Colc ) or rhrr hcorshc iscxcmpr rh.Eliotrrridrlr br\is fitr rh. rllcg.d crcmrrion AnyriolarionolSccrion Tlr.l l.5 hyatry
<br />apflud ror. pcnnii \uhjccrsrhc lpplicanlk) ucivilNn,hyorior nkftrhdn fiv. hxndrcd dollds I $5m)
<br />-1.
<br />ns oprcr of rh. rolrnr. (tr .ry.nlploj{cs sirh sascs .\ thcn solc c.nD.ns ion- qill do lhc sork xl rhc {trrm 6 mr
<br />i.rcfrlcJ or ollcNl r'or sk lss 7044, Busircs dd Pr.f.ssi.nr C{tc Th. Contadols Liccnr ljw docs nor {plylo an owncr oi
<br />rhc nnrFny tho hildsor impm$\ lhc@., ond wh. dessehwDrkhims.lforhcr€lf.rrhmughhi\ or ncr o*n cnploycc\.
<br />,ovidcd rhrr \u.t i'nprorcrmnr\mfrn mrcndcrl orufidrrlftn {lc la trecrc. rlt britlio8 o, i.rqrerqror i bkl wih ,{c ]{0r
<br />oicoDllction. rhc owrcr Build$ willrLNr rh. h.d.n olpmviry th( hc or sh. did nor build or inDmvc thc fmlf,ny ror rlf puqb* or
<br />l.nso*nrroirhcnmn ny. rcxclusirclycotrkr.rir8 rirh lic.nscd codracn \r{'.1rn{flcirlEtnol(i(scc 70tr.llu!n.,\
<br />rnd lhnisliriCodc: rhc C.nrrcrn s l-icenrc l-rw docs nor rlipttr. nnosrcr.flrot ysh. huttdr.r i'nFov.\ rhcrcoi,
<br />and sho Ntrhd s n)r su.h pfuj.rh wirh i ci r .k,n\Iliccn\cd pu^unr hrhcconrscrois l-i.cnsc ltr+1
<br />I rn.xc'nfr trndcr S.diu, . B & l,( ]nrrhs rrx\tr,
<br />Dal.: O*rcr
<br />uoatr!&tlou[ElsalloN
<br />DECI.ANAION
<br />I hcrcby aifiln hder ocnalry ol rcriury orc oI rhc lollowina d..laarions
<br />I hrvc and willroinrlin ! Ccnirrorc ofconenl to Scl nsur. rff $ork.E .onpensrriod.ar povidcrl
<br />lihor Code. for th. rcrfonnrmc of$c work for shich rhc ncrnri is issucd.
<br />I hrr and (illarainrain $orkcrr c.nlt.nsrrion insutun.c.,\ rcquftd hy :r7rr) ofrhr tnhor (htt.. fn rtu |f,rrnnun.r or
<br />rhc q0 I lnr \hi.h ih \ N
<br />Crtrrr: .
<br />_l .cniry th r h ihc p.rroirmn.c orrhc w.rk ft, which rhi\ n.nnir i\ n\ucd. I shJll
<br />vr a\btrcoE sublc.r r.rhc workcn dnnpctrsdi.n luss.f Crlif .in. nnilalEc rh
<br />, rn, Pe^on in rnynrnncr
<br />work.r\ rotrl|r.n\rri{trr ptr]visi,'o\ ois..riln JTlx).l rlt Lrhr cix]c.l rhrll. ftn
<br />WARNINC: ,, lurc k, \c.oic sorkc^ .oi1Fn\in .ovcrasr i\ unhwlnl ud
<br />civil nrcs un tr om hudr.d rhoustrd dolld\ (Sl(n.o(nt. in addi
<br />Sccrtrr.1076ol rhc l-nlrn (-.xlc tr .rc{ rtrd rronrrnr n.\
<br />DI:CI.Af,AIION
<br />I hc(hyairirmunderpcnrlryof pcrju,ylhar Irnliccnrdund.rnmv6n .rchifr
<br />ol Ihc ausir.\sdnt Pr.ac\si,{\ Codc. d nrr liccnsc n in full f{r.! utrd .tlccr
<br />nrRing *nh S.ctin ?olD) ol Division l
<br />v6+t 6T
<br />Y (lJsl}!!l!.0!LrN.1!l!j-.!!r,\1-r
<br />(4.i::".i.,J'.ffi:Ifflr.f Friurrrhar rherc is a o,nsrrucrion kndins srcncy rhr rnc pc,rolmncc of rhcNork ro, wnich rnn pcn,ir h
<br />kndcis Nanrc
<br />l_(cn'fy rhrr rhc fc'lcrJl kEUlJr'oii rgfJ'nx r\h.n
<br />\:/c!iir) rh. rh cRlr,hh.nnrErrdn od {10*,hd r inlnnnrri()nN.onc.r Inarakico'ntlt*irhnllCfydndCoun(v
<br />ordinucc\ 3nd Sllrc tjq\ rcl,rin8
<br />rbo\c nrflnnrd pnrpcnr lar ir!
<br />FApplicanl or AEenl sknnlure:
<br />Pemit.e nemrlpnn0: L
<br />,I t'"-""'"""aili;;
<br />ur'irrtIP I I
<br />Set Backs r l. I .-l. ra
<br />Forms/Steel/Holdowns v t,lo \UJl
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Bool Sheathinq Z tt9
<br />Shear Wall 1 t*/,U4MFraming Pul,"J:WT tb tt(cP))9tu?5
<br />lnsulation/Ene rgy 7 .rq I
<br />D rywall d
<br />Ext./lnt. Lath 1lriil 7
<br />Brown Coat )
<br />Mason
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .rt I \-/
<br />---)
<br />FINAL R..I
<br />\C-ttifl-cate of Oc cupancy
<br />Ngtes, Remarks, Etc
<br />Tllq\$ Atta o( L )c./,1 79ott
<br />I Jl Lt*F* L
<br />a-/WL^
<br />ve'oc.lz,U
<br />lrl/,ITVI
<br />T VI \
<br />Subf loor/VenVl nsulation
<br />1l-7t
<br />E i llQ
<br />IA\G
<br />.A tl ,l I
<br />D \ L/v'
<br />.^
<br />1
<br />AITLI!:ANLDr:IIA.EAUAN
<br />I lrr$, limuddcr p.nalr, orpcrj0ry onc orihc tnlowins d.clirornrns:
<br />D.ntr,liri{r Pcoirs Ashcsros Norifi.,rion Fedcr l licSuhlnnr (Tirlc.l0. P{n6)
<br />R.q0ird Ilrcrol Norifi.rii{n,
<br />5fr+-#w
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