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BUILDING- INSPECTOR RECOHD
<br />SITE.WORK ID/SIG.COMMENTS OWNAR BUII,DER DELCAXATION
<br />I hc.cby a,llrm undcr Fn.lly oi Frjury th.t I nnr cx.mrr rftm rhc Coftrct,s l-i..n\. Irw ftn rh. nnk,wir8 r.av (S..70115
<br />Busi.cs\ and Proicsn,n C.dc) Any Ciry or Connly which rcqurcs r Fflnit lo conqd.r. rlrcr. nnrrcvc, dcmlnh or mlin rn,
<br />nru.rurc. ltrid b i( i\sudmc, al$ reqlncslhc flpplicanr rbr such pcrmilto filc a sisncd (ltemcnl lhal hcor shc is liccnEd plNuanr
<br />r) rh. provhions ol lhc ContEclm s Liccnscd Ljw (Ch.trn 9. c()m i.tr.ir8 with sc.rion 7fi)o or Division I or lhc Busirc\s .nd
<br />Pturc*n \Codc)orrhrr hcorrhc i\cr.nlprrhcrclromand rh.h.sis for lh.alL[cdcxcr.plion AnyvioulionofSccrhtr?0]l.5bylny
<br />aprlicanr lor. pcnnn su$ich rhc rmli.a.r h a.ivilpcnahyDrnor mn hii livc huidrcd doll$ (SstxD
<br />l. $ o*ncr of rhc 8)n dy. .r ny cntl{,tss *nh wrs.s ar rliet hlc conrcn\dion. sill do rhc \o!rt rnd rhc {Br!'r G ior
<br />ini.frl(l or oitrcn Ior slc lSc 7014. Busincs rnd Piorc\\i(,n\ Codd Th. Cont.ctr's Li.cns. b* docs nurnmly h dtr.$trcr ol
<br />rhc |x)J).dy who huildror in{,r.vc\ ihcfr,n. ind sho dcs $ch wo k hnnrcll or lEr{cli or lhmu8h his .r hcr os n cnDl,ryccs.
<br />pn,lidcd rh3r such i'lporcnxtrr\ rE mr inrcndcd doffcrcd fitr sslc ll h.sc\cr. rlrc hdilding or i',pmrctu i\ sold *irhi" (, r Jr tr
<br />of con{,hri{,n- nr Owmr Buildcr *il hnvc rtE hudcn of F,vii8 rhar h. o. rhc did kn hril] .r nittulr rhc pn)F-ny fG rlr pqbr ol
<br />_I.asowncror'hdptutrdr.r d(lusilclycoik3crin8wirhliccnsedconrrncrnsroc.n(ruc ncp(*ct(S.c7lrJ4_Bu\inr\\
<br />and Pn'16\ionCodc:lhcConitrntr\Li.ctrscLrwduc(trorrprlyrond.qncrorroFnywhohuildsornnprov.srhcrc.n.
<br />.tu1 who..nracrsln.skhpojc*snhrconhcro(rliccnscdpuruan orhcconrncrolst-iccnscl,i*)
<br />I d r.xr r undrr Sccli{l
<br />Dnle: o*nrr:
<br />rvoR(r'Rs aonrriNs'r'roN
<br />DECI/BAIIA!
<br />I hcr.l'yaflnmtr crpcnllryof nlrirr]oncofrhchlhsill!dcclttrdions:
<br />-lntrv.udslllmiint.iinCcnilic0icofConsctrrtuSclflNrrcf.rworkc*.omtNiliotr.rs!6v
<br />cd hr by Seriotr :tT(x) ol rhc
<br />rihor C.dc. for lhc pcriornr ncc of I h. qork forwhichrh. p.mrir i\ isNd.
<br />I[nnii n i\sucd My qork.^ .,nnFnsari,r ir{trin.c.rri.r ud lxnl.)_ trtrtrrblr rr.
<br />I
<br />I.cniryrhrr nrrhr raonnaircol rhc work nr whichrhn |{nnl i\ n$'cd.l \hrllnorenpl,,y uryp.rwn, in rn, nuntur
<br />m s ro nccom suhtcd ro r he sorkcis conrl.n{rio. lnwq or Califoi,lir, rnd rsr.c rhxr if I rhruld h.om \ub ct b thc
<br />wo cn corl|ttrsd i(!r ptuvi\ions of Sccrion 37m of rhc ,ilhtr C{xlc. l \hrll, fon hsirh .o'nnlt *irh rhor [ovi(ions.
<br />WAnNIN(;: Frilud o \fttrrc workc* ..nrp.nsrli,,n.1,vcr gc is u.llwlul. r \h3ll slhjccr an cmpbtcr t, citrri0rlpnrhic\ rdd
<br />civrl fircs xt tu onc hndrdd Ihou{r d d.llrn lslfi).(xxD. i', ail(liri,'n t, rhc co{ ofco'npcnssrion, da h!.\ r\ f,vd.d litr rhc
<br />Scdlotr 3074, olthc LahtrG)dc. i cmstn d onry \ ic.\
<br />"UUN 11 2ot0 t)licl,,\R\ I l()N
<br />I hcrebyarfirm undc, Fnahyoip.UUry rhlr I am liensn undcr Eovtion oiChrprcr I (commminS nilh Scti,n ?(xlr) oil)ivnion 3
<br />of rhc Busimss anti Pml€ssiorNCodc. oNl rvli.c.( ( in rullritr.c md.ftNre lotlw.
<br />rolErf,ue rxLlillllNri-acENLr
<br />I lErch, anhnuMcr F diyolp.,uryrh.l thc( h a.on{fl.ri,n h.ding recncy rd rh. lcrronmk orrhc $ork tu which this |gni t
<br />issucd(s( .l097.civ c)
<br />AltltlANtDliClrlXIIlON
<br />I h.eby rmnn uM.r !.nalry of Nrur, on ofrhc lolk)*in8 dcclarlri,,,1
<br />Dcnxniion Pcnnik Arhcdos Noril_'carion Fcdcrol Resllarion\ flirlc 10. Prn6)
<br />Rrquncd l.x.r ol Norifiur on
<br />l.dril_vrhrr rlr fc(lcrrl'cgtrhli) \'.!rdi"grsbrno\'.nn)[l3rcnor]lfL.nhLcti1l,i\In)j..1
<br />niry rhd I h.vc cad rhtqrplicrrion ond narc rhir rh. rhr!. irbnr e ro.onrly *nh rllCnyrnd (bunrl
<br />ordi,[mc\ rftr srrlc li*s rcrrr i'rs h huildir
<br />ah,vc nrnlion.d prcpcny hr inTccli.tr lrur
<br />( iryrni ( 1nnn)_ r..nr.r utxr rlr
<br />d A,u
<br />J'[it{LI ?018
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SublloorivenVl nsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />lnsu lation/Energy
<br />Drywall
<br />Brown Coal
<br />N/asonry
<br />Pool Fence
<br />T-Bar
<br />Handic Req
<br />De ut Final Re rt
<br />Flood Zone Certif
<br />FINAL {/2u lt6 A6t
<br />Certificate of Occu pancy
<br />Notes, Remarks Elc
<br />1
<br />DATE
<br />SLAB Floor
<br />Framinq
<br />Ext./lnt. Lath
<br />Enoineer Final Report
<br />*.JUN 1 I ?018*"**.
<br />l rld.''r Ad&.s
<br />Amllcanl or Agcnl Signnh,E:
<br />Pemile mme {prin0:
<br />f T------
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