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BUILDING. INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS ()\!NltR BlIl,DI.iR t)Lt.C]\lll l l()\
<br />I h.rcby !fiirn undcr pcnally of r.rjfiy rhdr Ln cxcn1fl ro'r rhc Co ra.xri Licci* t2* ntr ihc r.llosir8 reastr ls!.7r'il5
<br />Businc\s snd Pmrd$idr C.d.) ny Cily or Counly which rcqlircs a pcrnir t, c.nirucr, rxcr, iqrrovc. dcnblth or mp,n 0n1
<br />sdcrur.. pri.ro irl hsutrmc. lho rciuncs rhc appliclnr for such pcrni t) fih. siSncn sar.mtrl rhat hcor shc is liccn*d Pmuunl
<br />ro thc prolnions of rhc Conr.r.kn { Li.cntd bw lcnaPl.r 9. Connmnci'rs sirh S..rtrn 7fix) ol Divnion ] ofrhc Busincss and
<br />Prcfcs\n,nsG)d.) orrhdltro!shc ncxcmpl rhcrcliomandlhcha\n ntrrh. rllcScd.xcnflion Anyviolsrionofserk,n?'rrlrbirny
<br />ipplic.nr ior r !.rmil subJccr\ lhc lprlicsnrt,acililpcnalryornor brcrhrn fivc hutrdrc!dollm rs50o)
<br />L rs o*ncr ol rhc ,rclcny. ar nry c rloyccs wirh {rgcs ar rhcir {,lc .otrrJf truri.n. will do lhc trort rfrl rh. ddm '\ r,
<br />inrcndcd or ollcrcd nr vlc 15( 7184, au*i'ic\s r A'ofc$ion\ Qtrlcr 1lrc Onrn(tn \ l-irn* L'q ilocs .or rpplr ro in otr ncr of
<br />th. pmttny uh) la'ilih.r i'ryovc\ rh.mn. md *tx, nrf,s \!.h tlrk hirnscll o. hcrclfar rhrough hk or hcr own cmf'loyccs,
<br />F)vid.d rhrr u[ i'q'n,vcmnrs N nor inrc cdoroiircdtorelcILlxN.rtr.rhthirikiir8o.DuovcmDris{nd*irhi""irttu
<br />.fcomnhrion. rhcOwmr Build.'sitlhr!.rh.budcn.iproviD! thrt hco.shc iil lor hrild or i'nFror rhc pm!.ny lor rhc Purlns ol
<br />l. $ o\Nroirlrc I()n.ay. rnrcr.h\iv.l! coih.iin8 trirh licctrscd ..nrricl,tr\ tr).otr{ra.r rhc In,rc.t lsc..7(11,1. trusnc$
<br />n rh,f.\si{n,Coc:lh.Cotrtrr.rtrsl,iccrscLrwdocsNrrnnlybrios.roffrofcrry*h(ihnildrorirnProrsthcrtoi.
<br />n.l *h. ..nnrhlnr\uchtx)i.crs*hhnCotrtr.b(nh.crrcdflr\u rrl{)rh. Onnrr.tr's LircNc LnN)
<br />"!",t: I t 't ){11-4a >z-r'2
<br />DlicLABAurlN
<br />! hclcbyiirilnundcrri{ alryor!.rjxryotrc.rrhcLllostrrEdcclt,iliu,s
<br />-l
<br />hxvc and iill'.rinrrinnC.nifi.rrcol aanscnl to Sclf.ln$trc li,r $o'kcrs inrnriui.n. is Jtr.vidcd fo!hySecrn,n:lTmofrhc
<br />Utior Codc. tu rhc Frfoirnrdc. of rhc rorl foi whi.h rhc p.nnir i{ isu.d
<br />lhrv..ndwillnrirrirlorlturiconDcn\lrioninsurancc.rsr.qtrmdhrSsrio.:t7lx)oliicl,!bo!Codc,forthclxrlonMccof
<br />ihl Bork lor B[ich rhir ncrmir is is!.i nrysorkcrs Qrmpcnsdn,n ,nsurnrE .rflicr 0 nolicl nrnrh.r dc:
<br />*l.cnilyrhrr irrhc ncrlo.n, m.t rhc soik io. whichrhis D.nnil i\ lsntJ.I \hrlliorc lroyrDyfcrvlr ir tny nt tr d
<br />v' asr,lf,.o ,c suliLrr t,rhc s.rkci('c.nrFn\rri,,n lrMolCrlir(tr i], rtrrlrsr.c rh ili \lnn,l 6..onr \uhjc.r r.rhc
<br />s.rkr'i r. t)ctrqri( fr)visiofl\olSsti:17(xl.lth.trtxtrCodc.Inrll.l,rlhsirhdnflysirhrho$t,mI(ion\'
<br />IVARNING I' ilurc b {cur. *orltcri coml.n\dn .ov.nt il utrl{wli,l. od srHll {rhEcr
<br />'r
<br />cnrflo}tr ro d'nifrlpcmlric\ and
<br />ciul llN\ u, ti onc hundrrl rhotr\rnd d.ll*\ (S100.{X)0 l,iiriLr r,' rlr.,^r o1.f'*';,;:r;.:-*
<br />u*", |!21 L 0tl
<br />DEIIAEAIION
<br />I hcrcby lllirn unJcr p.nrlryolrcrjury thlt I am liaocn uftdcr povirion orchtlrs 9 (comrEmins $irh Sdrion 70m) ofDivision 3
<br />.a rhc Bu\irc$ ,nd Prclcsio.s Codc. .nd my liccns h in lnll tore 3id cffccr
<br />COBSIATX.DONTENDINCIAINqI
<br />is rd{Sc. 1097, Cir. C.)
<br />t ndo . N,r'c'-
<br />APPI ICANT DECL{RAjION
<br />I k y flfiinn umlcr nenalr, orp.rjury oft orrhc lblbsnre dcln.ltiotrs:
<br />D..rlilion Pc nirsAshcslos Norificlrio. Fede,al R.gola!ionrlTnh {0. Prn6)
<br />R.qun.d kt(cr ol Noliltarion
<br />-l
<br />ccnifyrhor rh. Ldrrilrc*Uldions rc8 dirg tE{nsrcnr)valrr.rcrritli.nhlckrrhispro]c.i
<br />I ccnrlyrld t hrv. rcl(l rh \ npplkli,n, d {rtrhrr rhcxhrc i0ttrtr[i(r i\c.lrccr I"sRk,ro fly wirh r ll Cirr ud Coun(,
<br />ordirdtr..s nDd Sr{c t-r$s rhrilg ro hulltli',8 con{dct.i. rd hcr.hy ixrh.riTc rqrr.srnrrrilcs ofrhi\ Cny ind Countyt, ttrrcr rtrinrhd
<br />dn,vc nrninnrd nii)lrd! tu ii\lrdon frposcs
<br />ADpli(ntrl or Aaut sil rh'
<br />o:Li.cl or,tl rY?a u L fzz
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVl nsulation
<br />Roof Sheathino
<br />Shear Wall
<br />Framino
<br />lnsu lation/E nergy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It4asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />I/l /2u',FINAL tt{ .#afirl
<br />Certilicate ol Occu a
<br />Notes, Remarks, Etc.
<br />SITE.WORK
<br />/s
<br />fasc
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