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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BTIILDER DELCARATION
<br />I turcny rflnn uMcr |Enulry or p.rlxry th l in.xchU tonr rnc Corkrclri l-i.dns l-,w ror rhc thllo*irs rcan'n (Sqc.70ll.5
<br />Busincs\ and Prolcsion Cod.): Any cny .r County which rcquncs r pcnnir kJ &nr{ru.r. allcr. imProw. demohh or tpln My
<br />srocllrc. !.ior rr ir\ issurN.. iho rcquircs rhc 0p,,lic r ror slchFrn r. filca siSnL'd n cmd lnar ncor rh. is lic.nql N6udnt
<br />lo lhc nmvisions ol lhc (in rador's Li..nsd tis (ChrPrcr 9, C.nrmcmin! wirh Stcrn'n 7Ux) of Divhion ] olrhc au\nts\ and
<br />PR,rc\snrrCod.).rrhnrhcorshclscxcnrplrhercfronrandlhcbasisadrhc"lrclddcxcnUtun.Atryviollrlonorsccri,r'70315hrrny
<br />.pFli.nfl tur. p.rnril suhl$lsrh. lrplicanr b a.i!il Fmlry or n.r mrcrh!tr llvc hundrdld.llih(S51xD
<br />]1QBK!8IL.Cj)!IIENSAIION
<br />lLcLASAuo!
<br />I hcrchy affnm undcr r.nalry of lcrrury otrc ollhc lolloNins dcc|ralioos:
<br />llrvcn willmlinlrinaCcnificrrcofc.n{trr r. sclf.lnsuru for workcr' lrnlPcn\ n,n.0slovid.dlortrySccrionlT(nofthc
<br />ljh.rC,dc.fttrrhclcrLnnrnccoflhc*orifrshichrhcpcrn,ir i\i\\u.d.
<br />Ihovcanduillmlnlnrwor*crsronrp.n\dioii.\urun.c.r\tquircd6ySccrion:l7lx)ofrh.tihorCodc.lorlncpclfortun.cor
<br />rlr Bod tu whichrhn ncrmir i\ i\sucd Myworkcs conD.tr{diur iNur(mc ca cr aftl lxllky nun$cr dc:
<br />a ricr-
<br />Polic, Nunrbcr:-
<br />-h...5lC/Ld,[ r[ rhltul,t,n.rrcii'rhcNirtIrNr'tr'rhi\Fnnir6\{ucd.Ishallnorcnrt]loyrn}nrrY nrrtynrutmr
<br />$ !sri lrc.nE rlhicd n,lhc tro c( c. rttrrsrri(lr liqsol Crlif.trril xnd rgrcc thdr ii I (h(,uld h..om lrhlcd k'rh.
<br />tr.rkcn..nrrcn\rti(nr|m)vi\i{,\olSc.riotr:17(X)ofrhctrhtrC.(lc.l\hrll.tunh$irhconrtlywirhrh.c,rrnvisidr\
<br />NARNINC I'll|urc rJ ccurc *or[rr\ co$Itri\rrirn)
<br />.ivil fin.\ rt, u otrc hrnJ.cd rho \ d.llx (l9llx
<br />s..rii 1076 ofulI Itrhr (-odc inrnr{mdr oi,r!\
<br />trr ro nimiMl pcru[ts Dnd
<br />,nE8cs a5 F)vidcd f{r rh.
<br />[*,. q-zY-i6
<br />I hcrcby {iftm undcr pcnrlry orprlury rhat I am licctr*d utrdcr pmvGion olCh{rci 9(.onnkncinS wilh Sari,n 7uD) otDiution 1
<br />of rh. aunrc$ md Profc$ions G'dc. ,Jri my lifun* i\ ir full for.c ud clltct.
<br />61,.
<br />F',". 5 z{ r< }
<br />t h.rcby rlItrm under rEnrllyofncriury rhar rhcrc is i.oDnnRrb. Lndir8 tr8cn.y fu rhc r{rronrun.c olrlE qolk fln whi.h rhit Ennil h
<br />n\ucJ (S( 1097.Crv C)
<br />AIIIICINLDECLASAIION
<br />I hrht trflinnund.r tctrAlry ofpcrJury onc oirhc f{,|i,*in! dc.lrdiois:
<br />Dflnolinnr P.rfrh+Ash.sos Notificllion lrcdcrul Rc3rlnri. s l-Iirlc tl0. Pin6)
<br />Rcquirud t trc.ulNoriication
<br />#"-li rlrxr rlr l.d.rrlrcrnltrr on\ rcgrkltr,t r\hcio\.rnn,vnlrrc hr ll)fl.rhl. rl
<br />I rBrN ro c.q)ly wnh all Cily aid Coxnly
<br />div.s olthis Ciry 0nd Counryro.nrcr u|mn lh.
<br />hit I hrvc rcad rhisrprli.di{,n Jxl dddrhrr I
<br />ordinaNcs dod Shlc Lis\ rchr ing io huildi
<br />ftov. nrtrri(,rd DmNny hr irs
<br />kpp coir or
<br />^*err
<br />s
<br />>l'rmilee n{nre (p.inl)Z 5 -z\ee
<br />Set Backs ,A
<br />6-K"]Y
<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 Coal
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />Frrrr\/f\&L nr/q h-rrP 6-7E-lY i
<br />FINAL
<br />Certificate of Occu nc
<br />Notes, Remarks, Etc-7-Jl-/y: (e,eJuff, atY x/*tl,-
<br />Forms/Steel/Holdowns vfw].,)
<br />Shear Wall
<br />-i
<br />)|rl)0
<br />(
<br />-1.
<br />&\ owicrolrhepmpcny.o.mycmFlorrcs Rithwascsus lheir sk conFnrarion. willdo r,E worl url ltE srBrm is mr
<br />int.ndcd oroocrcd ntrsb(S1r.7M,1. Bosinc\sand Protcsions Ct dc: Thc Cotrnocbis l,kcnse l,aw do6 o.r rrl,ly to otrnqol
<br />rh. pmltny *ho t ik]\ or i'npr.vcs rh.mn. and wh. des smn $n* himscll o, hd*clt .r rhtoueh his or hcr own cmpk,yccs.
<br />[ovidcd rhor such imnmwcik m nor idcnd.d d ofl.i.d for $k lf. howcvcl rhe hilding or impmwm k $ld wilhin onc JU
<br />or conpLrion. *r oumr Buildcr will h.w thc bnr&. or ptuvin! rh,r r. .. sh. dil mr l{ild or iqet rhc lmpdy ror lh. puqn{ ol
<br />-1.
<br />as owmr of rfic pnpcrrr. a'n cr.lu\ivcly .onh.ring wilh li.ctrsd conrroclon lo coNo.l rlE tn,i\l (sc. ?014. tsurinc\
<br />and Asft$bn C.dcr Thc Contr.clors Liccnsc L0u des nol anply ro anowtr.. ofrmll.nyPho $uilds or imPdwr rh.rm..
<br />and wno onrEcts for su.h proixh wnh , (rrnrDd.rlr) lkdl*d pursunt lo lhc Co.r,Dct, . Lhcns. bw).
<br />I amcxcmpt undcr Scclio.- a. & P.c. tor this rco$n
<br />Dsre ()*mr
<br />lf,n'lcr'\ A'ldr..
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