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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE COMMENTS OWNER AUILDER DELCARATION
<br />I hcr.$y aflnn undcr lcnolly of pcrjury rhd I m cx.nu fmnr the (hnrrrcroF t,iccn\c Lrw l'or ihc follo*ing E,$n (s{.70.11 5
<br />Busincs rnl Pn,fc\sinn C{xlc): Any Ciry ur Counry which Equn \ a Fiinir i(, .oh{ .r. !lrd. inllrov.. thnhlish or Elon any
<br />{rucruic, p(n rr ( nsu0ncc, rlso rcquncr rhc qrfli.rnr lor such pcnnir ki lilc a siSmd (arcrEni lh,r hcor shd G li..nsdd rur\oa.r
<br />r. rh. pmvisions ofrh Cohtrcttr s Li.cnscd tis (Chrfl.r 9. (bmnrncin8 qilh Scclion TUJO of Division I ot rhc Bu\ims Dnd
<br />Pmlcssionr Codo or th.l hcorshc n crcryrt rherclionr!trd lhc ho\i{ Ior lhcalb8cd cictrrrbn Alylii,hrioh.rssri.nT0rl5btrny
<br />lpllicln! lor r pcilnir sufilcch rhc appliclnr l. !civiltcnrhyolnot nncrhrn live htndrcddolld{(!5([)
<br />l. rs .strd or(hc pii,|xny. or my cnrfl,Dt{r qirh qrSc\ a\ rhcir slc cnnlncnrllnn. $illdo ltE $ork rnd rhe nturh is mi
<br />i cdcn or.ftere'i lor $lc lss 704t. Busincs and Pmfcsiotrr Codc TIE Conkrcroi\ l-ten\c tiw do.i nol.prlyio an owftr or
<br />rhc 0n,Fny who huilds or imprcws rtENn. lil $h d6r su.h s o't hnnsclf or hcrslf or rhmuSh h n or ncr .*n rmrk,ycc.,
<br />nmrid.d rhar surh imrorftih e Rn inrcnded or ollcEl tur wL lt hfltrcvcl rtr huik]inE or i'rpr.v.nrnr is bU *irhln orc yrr
<br />oico'ry'lcrhn, rtu Owmr Buiklcr willhavc rhc tordcn ol pr'!in- rM' hc or \he Jil nor ttuild or in{b\r thc pmFly for ltr purlIs oi
<br />I. r\o$n.rofrh.pn'pcny. n crclo\ivcly ronrrd in8 wirh licr \cd ro tr.k$ r' on{o.r rh. rn,rd (Scc. ?014. Buw$
<br />! lhic$inCodc lhcConlr.clors l-iccnsc l,as docs nolrlDlylo ano*ncrolpn)p.dy*ho huild\or impr.v.s rhcir$n.
<br />rn who conrrrch for \u.ht r*chwirha c,nrruct,r1\J ltrtr\cd !!r\ur n, rhcGrnri.kr'sLi.cnsc bw)
<br />l mcrctrrnru .l.r Sccri,in .B &P('r,nrhAr(nrr
<br />Dulr O*ner
<br />l]!BrI&):(AU&!l lIA!
<br />I2E(t .BilION
<br />I h.rrhr_ rllnDUtrdrr nrDrlryolFq r!on.oIrhr tulk){i',S J.rlrrr otr\
<br />lhNcJxlwillnuinrrinrCcnilrJrcolc{)n{trrt'Scllln\urcturtrfrt$a..nrEn\ati({.a\tovidcdlnhysccri.n.l?(xlofrhc
<br />litxrr Grdc. nnlhcnc onunccoflhcwork fnshichrhcpcrmir k i\\ucd
<br />flha\rrndNillnrinrrinsork.rr..n,Fn!rn,ninsu'rncc.n\r.qurcdhr_sc.rrr:lTrxr.rrhctrh.rcodc.rbrrhcpcnonumcor
<br />rhc work fd shKh rhi\ Fnnir i\ i\\u.d Mtw.rlfJ co rFn\rr( i'r\unn.c.rnicr and Dolicytrtrmhcr rc
<br />"*^, S/o*c fun"lloJety
<br />-lccniiy
<br />rhlr in thc pcrform!rce oirh. work for $hich rhis rEmir n nucd. I rhlll n.r cmploy any FcN,n in rny m,trrcr
<br />{, $t,bcL\ntu bF.r h ih. work B comp.isari{,. h*s olCshnrrix. and r8m rhd ifI lhould t{com ruhjccl ro lhc
<br />*011.6.o'ntnsnrn,ntmrisionsofS..ri{rn.l7tl)ofrhcljhrCodc.lshill-fonhwnhconrplyBithlhoslrcvhiotr\
<br />NARNIN(;: FailuE ro ecurc wortc compcnsliion covcrr8c is unlo*tu|. uBl \hrll suhF.'' &n cnpk,rcr io mmin.l ltmlras.trd
<br />civil lin.s up roon. hundrcd thousatrd dolla r3l00.(xD). in.ddirion ro rnc co( nf conpen\lrion- dr'tulG ds provii.d for rhc
<br />S..ri( rrrT6flrlr l.rhn(i !. tr crc{ r rnor'f,y'\ lir\
<br />7-/6 -/ 7
<br />LIIIMEIII:ANIIAflAB
<br />DECI,AAAIA!
<br />I h.rhy ilftD utrd.r Nnrlryufl,.rjurr" rhd I i lidn{d u,ilr rn)rtion ol Chipr( I(omnEncin8 riihS.crbn7(fi)) ofl)ivisi.n l
<br />ol rhc Bo\ircsrund Pronsi{rn\OrJc. ar mr liccns. k in tullf{trft cflcci
<br />sKzGr
<br />,,.,. 2-16 -7 1 L{.a""i ?*.€,/
<br />IAXSIBIqUO!IENII!CI!,iE!(;I
<br />I h€aby n,fird uod.r I].mlryoIn iuryrhar rh.e ii r coond.ri,n Lndi.g ag.my lor ttE FlornErc. orlhc work for shich rhi Frnn i\
<br />hsu.t lscc.3097. Ci!. C )
<br />aPr[caxtDE!:tdf,A1lr1!
<br />I hcrcty altinn undcr Fnalry ol l)crjlry om of rh. Llhwins dsluari.nr
<br />D.mliriotr P.rnits Arheslos N.iific.rion Fcdcml RcSulari.ns (T nh (], Pan6)
<br />R.qui6d lrtrcr of Nonfrorb.
<br />_l ccnifyrhar r hc fcdclll Egnur ioos rE &d ing r\b.d.s Eturvrl .r. to Jrpli.lhl. to rhis pmrcr
<br />:Ll ccnrryrhlrI hlvc rcJd rhranl,lrlri.nand qorcrh rh. above itrlormrion n comcr I asd rd .oflt ly *nh all Cn, and Counly
<br />6fu un! c( rlld srrr. h$ \ Elinns ro huldhs cnnnru(uotr. ad lErchr .urhrizc Eprc\enrdivcs of ihk Ciry ..d Counly lo .nld uF.n th.
<br />I'.m,ike nnnrrprint), Oo an, 'aa 1/<"*,on
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subfloor/VenVlnsulation /
<br />Roof Sheathinq 7/V ? //q Fl T,4tttl
<br />Framino
<br />lnsulation/En ergy
<br />Drywall
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />It I
<br />FINAL 1/1A/ lA Azo
<br />Certilicate ol Occupancy (l
<br />Notes, Remarks, Etc
<br />ID/SIG.
<br />Shear Wall
<br />Ext./lnt. Lath
<br />C.t q
<br />I
<br />L.nd.l! .{ddrE$:
<br />-
<br />,,,," 2-/6'/r
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