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BUILDING- INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNER IIUI[,DER Df, LCANATloN <br />I hcrcby rfirm un,icr ptn y of rrjury lhol I !'n cicmpr rmn rhe Conl.lcroF Li.cns tiw lo, rhc r.lLsira rc,Y,r lscc 701 1 5 <br />Busincs a*l P.orcssion Codc)r <br />^tr, <br />Ciry or Counly whtn rcquitcr a pcnnir ro otr{rucr. alrd nnpolc. dcmolhh or rFri unv <br />{ru.rud. priorro ns issu cc. al$ rcqu,es thc lprlicor lor sxch p.rmil,o filc! \isn.d {drcmnt thlr heor sh. t licct$d Pur\trur <br />ro rhc |](,visionr olrtr Conrruclor's l-i..nkd tjw lchaplcr 9. Co@ftin8 wilh Sccrii 7(xx) ol Divhion :l orrh Rusnrs rnd <br />l'ft,fcsnsCodc)orthrlltorshchcxcmplrhcrcimnandrh€hasirforrhcallcScdexctnliotr.Anvvi.UrionofScclionT0.lltbyutry <br />rlDlic{nr foru pcmn subjcls rhe amlicunr i{, r civil p.naxy oi not mrc rh,n livc hutrdrcd dolles (s50o) <br />l.rsoprcroilhcpmpcay,ormyc,IrPloylisNilhwascsdsthcnohcorDeisdn.willdodE*otkddrhc{rucluisnn <br />inrcrlcll or olTcrcd td eL lSe.?O44. Businds rnd Ptrfcsions Codc TIF Conhdols Licu\c Ii* docs tror 0plly b mo*ncr oi <br />thd pnfny *l$t ilds or improts rh.mn. 0nd who des such so himcli or icrslr or lhn,ugh his or hcr osn crynrvcc\. <br />F)vidcd rhrr such i'npmrcmnls @ nor inrcndcd or orcBl for elc ll ho*.v$. rh. burtlitB or inPmwmnt is sld *irhin r 'nc )tr <br />of.onqrhrion. rhc Ow.cr Buikln will lurc llE tn8lcn ot ptuving rhd h. or she did nor buiu or i.{rok rhc lmFnv for ric purllr{ of <br />t. rs owEr ol rh. rropcdy, r.r crclusircly co.rracliry sirh liccn*d .onh.nrn k' $ {d.r rh. Imj.rl (Scc 7O4'l Busirc$ <br />i Ploic\st n Codc. Thc Conhcroi \ Liccn\. Liw do.s nor 4Ply l{' sn ow $oflroncnvNlx,buildsorimnro!'srhcrcon <br />and shn smmds for such ln,Frs wnh a cl)nlruclod n licen*d lunu.r h lhc Cont,ctn \ Liccns bw) <br />_l !u cr.nU undcr Sslt,n-.)Zrn t- <br />DECIASAIIO! <br />I hcrcby llrt uidcr lcnslly ol lrlrjry o'E .t rhc nn hwirA dslarlrion\ <br />-l <br />hlvcsrduill truintrin a Cenificarc ol Con*nr b sclllNutc to. wo.kcs conrF-nsolion. !s Prcvidcd lor bvSc.rion 1r(xrolrhc <br />h$r Codc. lbr rhc Ftfonnncc of lhc *ork ru whi.h rh. pcnnil is hsucd <br />-lhrvrand*illnmi <br />.inwork.rsco Wns[nnr iNuratrcc. a\ rcquircd h! Sccriqr]7fi)ofrhc tihor Codc- for rh. Pcrl'nun'c ol <br />rhc $ork htr which lhispcnnir i\ i\lxcJ Mysork.m .onrP.nsrrbn insurucc cxrir nl FnicyNmh.rrc <br />P.licy Numtcr:-ErPn.r: <br />Ircdilyrh[irrhcpcrionrn.cofrhcworklirtrhichrhi\lmnir^$nicn.I\hrlliorcrllrlo]lnvpcronhrnvnnncr <br />$ rs io h$oN s'hjcd b rhc solkcts c.nrFcn\xri{ h*\ or Crlrlorni.- rtrd xsrd rhrril I sh'ul(llt.o Euhjccrloihc <br />wulkcr'..nrNnsllionrn,visionsoiSc.lion.l?(X)ofrhcl-ahtrC.d. ! tlnll tudhwirh..mnlv wirl rhi'$ nmvisions <br />WARNINC: l:nilurc h s.urc wortcr'..mpcn\nrior.ovcfu8c i\ unhwlll. rnd rhrll q,6rc{r rn.ndoycr ro cnnri rl$m[ic\ 0trd <br />(ivil linc\ up ro onc huMrcd rhousrnd dollan (11fi).Ux)r. iD addilirnl h rhc r oi comncn\lrion. dalmgcs !\ piovidcd |or thc <br />S.crior:llr?6 olrhc ljtrrrCbdc. inrcrcd r anonry s {cct <br />Demtn <br />l2r!lllurar <br />I hcnbyamrmunder peElryorFrjury lh l am li.rnarl ond& Foviiion of Cnnprcr 9 (.ommmins *irh Sction ?OO0) ot Divi\bd l <br />ol rhc Bxsin.$ dd Pmfcssions Codc. dd n:y liccn* is in tull force dd cffc.r <br />c(lNsLRuc tr()N I FNDIN(; ACI'N(lY <br />I hcrchy llilrr undcr llenl}ryofFrjury rhlr lncc i\ tr.on{ru.riotr hnding rg.Iky tnr lhc Flr.flronc..fthc work ttr shi'h rhi\ F-nnil is <br />B\uctl (Sc. :l(n7. Ci! C l <br />APPL!CANT NF(]LARA'f !ON <br />Ihcrht imrundcr F.nalry oilcrjury onc.iihc lolhwitrs dcclmrh'5 <br />l)cnmliri{,n lt nir} sh.sos Norillctrri,,n }tdcrnl Rc!ul iors ('firk 40. Pnd6) <br />Rquncd klrcr of N.rificlron <br />-l.cniry'hrr <br />lhe fcdcml rcgulari.ns m8ardirs rsbcslos rcmovd m nor tpdicrhh b this pojst. <br />t enify rhar I halc rtxd rhh orPli.alion ud drrc thd rhc lhovc inromrn,r is comcr. I a3,e b.onPlv wnh sllCirtand Cbunrv <br />ordinomcs;nd Sr,rc tlws Elslina ro blilding consrfl.rion. and hctcbyamh zEFrcscnlurivc\orrhtCitvandCoxnrvr.cnlct!,nnrhc <br />otsrc mnrr,ncd DFiFdv to. ur n A <br />^pD,icm,mA*orsism,ur <br />y Aa.ri.,k t,)hNlu *n <br />penn,m,me,prin,,, .\?nfftk r fu-YtSrzt <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />Sublloor/Vent/l nsulation <br />Rool Sheathinq <br />Shear Wall <br />Framino <br />lnsulation/Eneroy <br />Drywall <br />Brown Coat <br />It/asonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL 7B///? t *+ut t>)Ol <br />Notes, Remarks, Elc. <br />Set Backs <br />SLAB Floor <br />Ext./lnt. Lath <br />I