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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE IDiSIG.(,WNER BUtT-DER DELCARATTON
<br />I hc.cby rmnnundcr llrtr0hr.r pcrjor, rh,r I m.r.nrrr ri.nr ihc Co racx,n l-i.c.{ Lr* rn rh. iollo{irr8 Bren (sac 70.115
<br />Busine$ md I'rotcssn,n C{xic) Aiy City .r Counry *hich rcquircs r Frnrir kt .o.{fl.r. allcr. inDovc. d.nr,lish or ftlrn nny
<br />{ru.rorc. rior k, ir\ h{tancc- lho rcquircrrie lppli.anr a.r suchrcrnirk, filc tr n8ncd slolcmnr rhrr hcor \hc is lEn*d purunl
<br />b rt* Irolisn,n\ orrh. Co.tl.roas Liccnscd ti* (Ch.fler 9. (i,m,ftn.in8 R[h Scction 7(IN) of Divisbn ] .f rhc Busirr.$ lnd
<br />Potc$,otrsCodcrorrh0rhc..sh. iscrc'npr rhcrcfro andrhchr!hfffrhcullcgcdc\cmprio..AnyviohrionolSccti,nTi).ll5hydny
<br />arplicanr nn!pcnnir \!hjLrrrrlr appl,crn o rcivilncnrhyolnol 'Bn.
<br />rhri fivc hundr.d doll s(t5OO)
<br />l. !! owmr oirhc fmpcny. or mrcdplorccs wirh s,g.\ r\ rhcn \n. (o.rEnsrlt'n. willdo rh. r'orl{.td lhc (Erm i\ n
<br />inrendcd ororlcrcd fff qlc (Scc 7o4{, ausin.$ d Prnfcssions Codc -th. Cd rmnn t l,lccnk lj* docs nor sF/, h inowrr of
<br />rh.F,p.dy who huiklr or illr]r)v$ l1- @.- md wfio J(r\ such work him\cltor hcnclfor rhmugh hG or h$ oqn cnPloycc\.
<br />provid.d rhar such in1P'.v.rBnts m mr i cdcd or ollq.rl ir sL lii howcvr. rh. huildin8 or inprcrom i\$ldwirhi .nc )eot
<br />olcomDtrion. rhc O$ncr Buildcr qillhdv. rh. burdcn offmvinS lhd hc or \la dil Fr hdiH or nnprolc rhc PmFny tbr dc rurF{ of
<br />-l.
<br />.s awncr oi rhc nrepcny. trn ciclusiltlt .o trdin8 wirh lietrsd conrrrctn () conitucr rhc l)rojcd (Sc. 7l]l]l Bu!trts\
<br />and ftrrsrb Q)dc: Thc Co.rrln \Li.cnsc t-a* docl ior rttlyro 0trosncr ol proPcnywh(, builds.r nn[ovc\rh.rc.n.
<br />and who codEck nn sucl fn*.ls rirh 0 conlmclons) lien{d pu^ur n, rhc conk.cxr's Liccnsc tr$)
<br />I rnLrn'nr un'lc' s\.,rrtrr tr &PC r."rh.'r.A r
<br />Dlt€ own.r
<br />'lvoRKElas' c{ rNt PFNsA TI()N
<br />DF(:LARATION
<br />I h.r.h, arfirn ond$ !$rlryolFrjuryoflc ofrhc r'ollo$ins Jcclmriois
<br />Ihtrv. dwillroi dr.(tdiicrrcolConscnrroSclfln\urcnxworkcn snrD.osllion. as Fi,vidcd for hyScclio!:)7(x]olrhc
<br />Lltxn Cod.. ror rh. p.rfonnrmc.fthc qolk for which rhr Dclo,ir is issxcd.
<br />(hc sork fr, shi(hrhr\ pcrmii is i\{rd Nly icr xlIn)lirynu $.r dc
<br />,z**,
<br />X\r,.'
<br />t )K J ArJ <\A G n'l
<br />r1
<br />.1;.n," *u ,(*')."".
<br />(0 t\\
<br />ro be.om subjccr b rhc workch roDDensotion hr\ orCrlironria.,nd i-!rcc rhar il I should trcom blcd to lhc
<br />sorkn\ co f.nurnnr ttuu\ions ol Scd ion :lTln of rhc l rhtr Codc. l slull. li)nh+ irh ..nrdy r irh rh.$ lmvhions
<br />wARNINC: lllilurc k, scurc workc^ co rNtrsdrion co!cri8. is unlx$lirl. nid \hrll suhFcl lrr cflrPloycr tJ diitrNl ncmtis od
<br />civil rlncs trp io oN hrndrc rh.tr{'nd dollar (Stm-(xD). in addiri{'n k, rhr.o{ ol.orp.nsilbn drnDrc\ 3s ffuvidcrl lor lhc"t"lTf'\"{
<br />l(,y'+t, I K AGCALftt
<br />LterN!4u!)Jrl!^(lull
<br />DECI.ASAIION
<br />I hcrcby,fltmundcr rcnolryofp{rjurr rhar I ao l!.cnrd uMcr pn,vGionofChaprd 9(.onrnrkinS wiln Sccrion 70({)).rDivhirr 1
<br />nr rh. Btr(in.$,nd PnntsionsA'dc ,nd 'n!liccnsc h h full lorcc ard cifccr
<br />(-r.s '[qS a](
<br />1{De tTA 5 (O I ,^-r
<br />caNsrSucuoNrENDlxli-[GIA(}
<br />I h.Ehy llltm undcr Fnrhlorpcrjrry rhdr thcrc n a oNrudion tndi'r[ tr3ctrcr lor lhc Pcrformnft orrh. sork irr whi(h rhi\ IEnnir ir
<br />i\\u(d lS.. lllqr. Crv C )
<br />AEEILCANLISCLAIAUON
<br />I turhy a6'nr undcr pcnlh, ol Frjxry Dm of rlr tnlbwin8 dcclararions:
<br />DcnDlirion P.rmils-Astrsros Notincario. Fed.ral Rceuhbn (Tnh 40- Pan6)
<br />R.quiEd tilcr of Nolificalhn
<br />\lllccn ) thd rhc,.dorl rexlnrtr'n\ reSrdrnea\h({ 'rcm'trrlmft indtr0hhrolhi\nnrrr
<br />ccnlfyrhrrlhrrcr.nil!hi\intllcrrionrrxl rrcrhrrrhcnhrc trrlonr kini\.o',..r lsldk'.onrPlysirhrllCiryrddCoufrr_
<br />o fxn.o\ rrd SrnL l.rtr\ r(hr tucri.n, rnd h.rcbl rurhoriTe rcpr.\.nrdircs.frhis City and Counry o cnrcr ullinll'c
<br />tui,vc nrDrioncd nr'!.dt tur i,r\Ikrinr
<br />6. r-l rt
<br />Ot\u1)pdionr olrsenr sirmrurr
<br />1**r* *.",rr,,, ,,/y'R
<br />-AG6..4
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulationi Eneroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />l\ilaso n ry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Beport
<br />Enqineer Final Report
<br />Flood Zone Cerlil.
<br />-9,,
<br />FINAL illl lrt 'i
<br />Certiticale of Occu nc
<br />Notes, Remarks, Etc
<br />1..
<br />COMMENTS
<br />Set Backs
<br />Pool Fence
<br />((
<br />p.nnir i\ n\d.{|. lnrlltror cmployrny pcr$n inn r rnNr
<br />Lcllc' \ Ad'l'..\
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<br />t-=
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