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BUILDING. INSPECTOR BECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS l)\vNl.R lll ll,l)lill l)l'll-{ .\R\ I lO\
<br />I hfi.by alfirfl undcr pcnllry of P.rjxry thai l ,n cxcnun lron, rh. conr0doF t.icens. hw ro. rh. iollo*iry mqrn rsrTolrs
<br />Busincs\ lnd Pofcsion codc): Ary ciry or counry Nhi.h r.quircs ! pcrmir t, conslrucr. llrer. inftuvc. dcmohh or Rlln ,ny
<br />dtocrrrc. rrinb ik issu cc. lho rcquncs rhc {rli.,nr hrsucn rrmn rr,iba si8ncd slnlcmn' rh hcor shc h li.cnsd Puisurtrl
<br />io lhc rmvision\ ot rhc C.trr&kx\ Licenscd Lrw (Ch,lr.r L connncnciDg wirh s.ciion ?uD oi Dirisi.n I .i rhc Buri'rcs u d
<br />P'ofcssioNCodc)orlh.thcorshcn.rc'ntrrh.rcfro atrdlhcbashtorrh.rllc8cdcxcnrPli{nr AnyvidrlionofSccrirnT(lll5byarv
<br />applrd n .lc.milsubjeckrh.,IPlicrnlloacivilpcnllrrornornkmrhrnlivehundr.ddolldrs(S5()()r
<br />-1.
<br />r\ ornrr orrhc Jro|Enr. {n nlycflnlo)Qr qirh Bucs N rhcn vrk conf.is,rion. silldo rhc *ork trlEntulrn'}n
<br />inrrnldi or oltireil Ior elc ( SR 7(44. Btrsincs md t\ofc$ions C{xlI l hc (l,nlrcntr\ l-i.ttr\c Ll$ docs nor aprly h rn owncr of
<br />rhcpn)Fnv qh. builds.r nnrxtr l}rron. Md *ho ducr nrh $o.k Ii'n\clfor hcr*ll.r rhmuSh hi\ or h$ own cmPl(rtcc\,
<br />prtr idcd rhir ruch in{ro!.nrnls !E tror i' c'rlflorollitod rar sib. lt hosckr. rh. btriun[ or imp('v.fl.il is sld *irhin "nu )t'tr
<br />of.otr{nclion. lhc O*Nr Blild.r qillhrE llrc int(lcn oil](,1i.3 rtur hc or \hc iid tr.r htrild or nnpnrvc rtc PmFny nn llc PU(IN ol
<br />L rso*rcroflhc pror.ny. Mrciclusir€lyconkrtin! wirh l,cc.{d contlct,E nJ..nqrud rhc pnrjccr (se. 7(114. BusiRs
<br />and t,IllsdJn Cod.: Thc Conllldoir Li.cnsc La{ d csnolapnlyloanotrn$olptoPcn,*h('buil&orimpovc\rh.rcon.
<br />a who conlEcrstor .h tn)ies snh a Conir!ct,(() li.cn{d pur sulnr k, ihc contdols Liccnsc u*)
<br />I inrcxcnrtn undcrSccridr-. B &P.C lbrlhkrcN)n
<br />D.l€ O{..r
<br />w0RKERS', COlllli!NS,{',l I(rN
<br />IIECLABAIIA!
<br />I h.r.by arrnn undcr,i.nally of pcrjury oic ofrhc tullowins dccbBriohs:
<br />-th,vclndwill'ninrainiCcnikardorConscnlnrsclllos!rcloruork.r.ompcnssrionxsProvidcdlbrhvSK'i'n17(x)orrhrLohr Codc. r{r thc PjtfoiiNrc ol rhc work for whi.hthc !'cnnir is isrcd
<br />I h!v. and *illmlinrai'r *orkcrl.onwns.lio! insuranc.. as rcquir.d bySecri.n]Tmofihc lihorCodc. for lhc !.rlo'nBn" .'
<br />rhc sork loiuhth lhisFrnir i\ isssn. My *orkcr' dr n1p.tr s,r ion insurancc crrif aM policv nunrl,cr ml
<br />c(€l
<br />5
<br />I c.nitirhrr i', rhcFnnnnrncc ofrhc work in $hi.hrhis |[irnn is it\ucd. lnrllDol cnrPlovrnr rrdsm inonv nMior
<br />$ a\t,1*o rnrhjcdrorlrcsl cn.annFn$t hwsoicrliinnir. d 4rcc rhlr ill should tr..nE $'hFr trrh.
<br />sorkc^ r. r.nlnriotr rn\ hion\ of Sr.rion .l7{X, oI rhc l lhn Crxi. l $.1l. ionh*nh c..Dly r ir h lho{ Invisi.ns
<br />*ARNING ljrilurc h --ctrN woricr $mp.n\rrnn,.o!tn,sc is urlawlul. aid \hill subicr aI xnlbvcr ro rinri'rl Pcnilrf,s ind
<br />ciril lics up ro o d huNl.cd rh.u$nd dotlas r). i. (tlli(i(r t) rlr ..{ ofconlxtr\rrn . damr3.\ s Pnivdcd l.r rhe
<br />'J;JIr14
<br />Ihcrcnyafirh !tulcr Fn,lry olrrjuly ihar I n liccnrrl utrdci Pmvisionorch{ncr9(conrnrn.in! wirhScclion 7fil())'rDivkion l
<br />of rhc ausirrs and Pr(rt$i(,n\ C.dc..nd my liccn\c i\ i'r ftll f(r( and cll'(l!
<br />ctlb ,4agl11
<br />S 1i
<br />CONS'I'RI](:TI(IN LENDINC A(:F.N(:Y
<br />I hcrc$y annn, tndcr pcn.lly ol Frjury rhar rhdc is r consNclion hndin! qctr.y for rhc pcrlortukc olrhc *orl ror ahich lhi\ Frnri' is
<br />nsucd iScc.1097. Civ C.).
<br />l.ctr{lcis Adrlrcs.-
<br />APPLICANT NE(:I ARAI'TON
<br />I rn$, nfinn undcr pcnally olpcriuryonc olthc lollotrnrs dcclaErtuis:
<br />DcnFlirioi P.imirs-Asncslos Norinc ion F.dcrrl RcSul0liotrs (lirlc 41). Prnr)
<br />_R.qun d L.rtcr ol Nol il-r.Diion
<br />l.cnitylhal lhe rcd.rrltuSul rion( rcArding nsh({o{ tom,vil u. nol il,Plicxhl. k,rh fmiccr
<br />l.c'rilv rl r I lr\.rcetnN rnpLi.n,ndd nircrhrrrh. trhovc irlitrD, inr i(.onccr t iaren,co 1PltsirhnllCiryrtrd (iru.rv
<br />ildirg .otr{nr.rintr. ani hcrcbyrurh.rizc rctr.\cnrdncs ofrhis Ciry!trd Colnry ro cnlcr uF). rltordinrncc\ rtrd Srrr. Laqs{ldin8
<br />ahrvc nrcnr oNd proFny hr in
<br />a Aorlo
<br />tl48
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Roof Shealhinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lrlasonry
<br />T-Bar
<br />Handrcap Req.
<br />Deputy Final Beport
<br />Enoineer Final Report
<br />Flood Zone Certif
<br />Notes, Remarks, Etc.
<br />Erection Pads
<br />Pool Fence
<br />?,zl,t*nll ,/tt --FINAL 7/,2 /tk
<br />Certif icate ol Occupancv t '' ' t w v' \'/
<br />If i'. Nrrn'
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<br />cl
<br />fT
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