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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.OWNER AUII,DER DELCARATION
<br />I hcrchy amln undcr p.trxlr, ot FrJUry rhrr I rn.tu.ry fmmrhc CoorrrroF Lkcn\c lrw f{tr rh. rdl{,sii8 rcrvnr (Sc.70.11.5
<br />Btr\i'rc$ r Ptr,rcsnn, C(x]lr Any Ciry or Counry whi.h rcrtunc\ r lcmir ro con{tu.r, , rrr, inFturc. dc.Fli\h ,{ rL.nrn Jtry
<br />nru.turc. Fidh iis tsuaNc. aho rcquncs rtx- apdicrnr irn'ch pc(nir b lllc r silrcd {dcnf, lhal hcor shc i\ liccn\cd Nr\urnr
<br />b rhc !'i i!i{,n\ ot iL C.ntrttr \ I-i.cnscd trw (Chrprcr 9. (onnncncing wirh Sccrion 7Un ot Divisior I ol lhc ,rurincs !trd
<br />Pn,rrsnnNcod.)orlhrrl[orshckcxcmplllrcrctioflrndlhct{sislorrhc,llt!L{cxcrPtrtr.ADyviohiionofSc.li,nT0.rl5byrny
<br />rtllicid n ilcflnir{bjcchricurplic h,.irilFiahtolnoriktrc'hrtrlivchutrdrcddolhF($5m)
<br />-1,
<br />r\ o*ncr or rh. pmFdy. or Ny cnrllores wilh NaScs !s rh.ir wlc conDcnslrion, wrll ilo rhc wtr* utrd lhc slmrurc is rn
<br />icdel oroficrcd lor slc (Se.. ?(}$. llsirc$and Prcicssions Codc TficCunrmct r Li.ensc ljB does nor sPpll r. ai olM.l
<br />rhc pn,rcny *ho h ilds or iqm\$ (hrB{. lml $k) das {uch unk hi.Nclf or hcr{lf or rhRtuSh his ff hcr ow. cmpk,ycc\.
<br />DmrAcd rhlr su€h iml)rorcnrnB rc nn inr.Mcd or otrcrd fi, {k ll hoscrc!. lh. hdiuiry or impotmd i! $H sirhin om )!tr
<br />ofconpLrk,n. rhc osncr Builhr will har lhc blrdc! otpnvins rhor hc o, \h. did ft, build or irtllro( lhc pmFny for 'tr purrt or
<br />I.i\o*trcrolrhctro|]cny.nucxclu\ivclrcontacri'rgNirhlicrtr\cd.otnrrurst,lrnr\lndrlEnr)jcri(scc704,1.11u\i'rr\!
<br />(nl lh)li$i(nr(intc'lhcclnntutr'st-rcr\cLrsdocstrorilflyt.rnorvncr.lln,I)C'ryNhohuildsorirnforcslhcrcon.
<br />nnd lho .o rr.crs lor \rchpnrcc!\*irhran rrctr,i9lirf'scJ lurun[ rorhc(iflrndoi\ l-iccns.l,rs)
<br />I rDcrcrrlx uM.r Scclion-. a &PC,nrrhi\rcason
<br />D.lr O*m.
<br />WORXFfS' (](IMPENS,{TION
<br />DICLAAAU!.IN
<br />I hcrcby aafi rmundc, D.nalryo,p.riuryoncorlhc rollowing d.clttr.rions:
<br />-thalcn
<br />willmai.t,inrCclic.olConsenrloSclf-lnsurclnr*orkc^comp.Ndiotr.nstolidcdforbyS(ri{,n1700.r'h.
<br />ljhtr Codc.lor rhc p&rorm,n..ofrhc *ork lor which thc Fmril h hsucd
<br />I hrw nnd will nDinhi workcrs conDcnilrn,n i.surancc, ar Eqxi6d hys..lio.l7t{, oirhc Llbor Codc.lorihc p.tfornuncc of
<br />rh. sort lor whkndis p.rmit is hsct. My w6rke6 conrFn$rn,n i.surn..c caricr lrd Flicy numbq uc:
<br />I.crlilyl[(i]rthcpcrlnniN!,nrhcwo'ktu'whichrl,nI['rir i' i$ncn. I \hnll nor .tr o]rnypcrotrr y rrtf.r
<br />v) n\ni hc.otrf, \uhj.cr h rlr Ro'kcrs.. rt'ctr\didr las{ofCrlrlarnir. tr(lxgrccrhrrifI\ltrrukllt..nc{rb}-cllollE
<br />tror(q\..n,rr,\di{rpntri\i,) \olScdl l7(x)olrhc lnh/ C.(lc.lshrll. ionh*irhcoarply *irh rll^c tnrvisions
<br />lvrtRNIN(;: Fllurc ro {ru.c sukc
<br />.Nrl lirc\ trf tr otrc hufldrcd ih.u{!
<br />n corrrr8. i\ unldltrl. d d \hdll suhjucr rn eddo)rr x, ai'nindll{fulra\ rtrd
<br />)o.lxx)). i', rddiri{r n) rhc.os r)f .onrp.tr{ ri,nr. nrnbg.\ ns l)n,v .d fttr rhc
<br />Sc.rdtr 1076 orrh. Lnbo! Codc. iircr.d
<br />"",",5- t r-20(42 Q,t
<br />l)l ( I \R\rl()\
<br />Ihr'.hyrllnn,undrrtrnrlr).1ttrrtrrylhrlItrmli..tr{rlurlLrIn,^ni,r,,,1(hrtl.rql.rnrtrNtr!*[h S..li,n 71)l)l)rolI)'\i:k ]
<br />01 rl[ Itu\in.$ rn,lPolrsi(nn Codc. rtr,l uylrctr{ r n n]ll kn(c rfttcllcct
<br />,.t .r'. rr^, O q81 ab
<br />o"r" 5?/5-
<br />I hcNhr rlltn, trn,lg |t htol,rrluryrhd
<br />k{'..lrsd. lo97 Cn C I
<br />isrc.trslruclior lc i,g rgrnct litrrhclcnnnn m olrhc work ntr qh'chrh s Nn I rs
<br />Lcnttcis Addrr\s:
<br />-
<br />]tlfuc NIlJLCLLBrtIlgli
<br />lhEhy rlllnnundcr pcnrlry ofn.rjry o c "frlc l,)lkrvrtdccltnri,nr\,
<br />l).nniriur l,.nnir\ Ash.(.s Noriiicrri,r r.dcrrlRCAUl ri(!F ( Irrlc,10. t'rn6)
<br />-Rcqriftrl
<br />l.drcr.iNorillc ri(nr
<br />lr.Euldior r.grnling r\h.{ovdxrrlrr tror rtJili.$lc k, rhi\ |n,+.1
<br />rcM rhi\ rnrli.rri,u xl{dcrhxr rh. dr,v. ()tororriqr iscotrNr I ns(r t, d,nrply *irh .ll Citynnd A,onry
<br />,riv.\.irhh Cnyand Counryto cnr( uF,n rhc
<br />*,., 5- tS.2otS
<br />0d hckhy aurtnriTc rcprc{nr
<br />s
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathing
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Beport
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL L-v - /O J)"1a7 c r{y)
<br />Certificate ot Occupancv
<br />Notes, Remarks, Etc
<br />COMMENTS
<br />Forms/Steel/Holdowns
<br />Shear Wall
<br />Pool Fence
<br />Poli.y Nuhb.r:-Extircs:
<br />trndc..NJnrc
<br />-
<br />(tut Qzrotr\\,t
<br />I
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