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BUILDING. INSPECTOR RECOBD
<br />ID/SIG.COMMENTSSITE-WORK DATE
<br />Set Backs
<br />Forms/Steeli Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Su bf loor/Venl/lnsu lation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />Insu lation/Eneroy
<br />Drywall
<br />Ext./lnt. Lalh
<br />Brown Coal
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enoineer Final Report
<br />T7nf///"//fr azltrf,FINAL
<br />Certif icate ol Occupancy
<br />Notes, Remarks, Etc.
<br />at1 Nt,jR $trn,Dr,rR Dlit,( 1RA I l()N
<br />I imcxcnrpr unddSc.lion-.'"L---o( - /7-t{
<br />DECIASAIIAN
<br />I hcrcby ainrn unilcr pcMltyolpdjuryorc olrhc fullo*nrB dctl.rarioi3
<br />lhtvcond*illn[inldin!ccnificlcolconsnllosclflnsur.f(tr*rk&{col!.nsali(,n'.sprelidcdlirlbysccli(,n]70ooflhe
<br />tiboi Codc. tbrrhcn rform.mc of rhc s.rk ior which rhc Pcrdi n nsuq,
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<br />havc and will mainlain sotkcs comncrsdn insurancc. rs rc+ircd hv Secr ion l7m of lhc ljhor Codc- t' rhr ll.rformrkc of
<br />rhc sort for which lhh Frmir ir issucd Mywotkcs conrpctr\a(nrn innmncc crntr.nd gnicv nun'bcr nrc:
<br />[\Pn.\
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<br />nor cnlPn,yany pcso. ir lnY iDnncr
<br />if I should bc.o.E sul,Jc.r ro rhc
<br />conrpl, wirh rhos !rovti0ns
<br />ll suhjccr cmplor$ kr diminrl frnJlas ind
<br />ot.onDcn\urii[ dlmacs as nrovidcd ftn rh.
<br />ao cr\ comFnsxtnrnprovtioniolSccli n l7(x)orrhc t-rhtrCod..l shrll. i{'nhsih
<br />WARNTNC: thilurc b \c.urc wtrIcB ..nlf,ns ion $rcrDlc i( unh*tul. ntrd shrl
<br />rr.l ltr'..un!'.irt h fircd Ihed\JnJ d.lld's '11'x'.'(}". m !J4ri'{ 1' rh( (_r '
<br />s.\r,of .ruhf r\.I,'h.r('nJc '.r-1\rrnddn,1.y'.rA. / a__*", oe' 11 ' | ? apprrclni: L^[c[NlEl]laNua!:lu.E
<br />Dilcl 4R T!(lN
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<br />I hrrchyrl'lir undcr p.nrlr! ol !.,ju.y rm r ur lic"n*.r tn,rcr F*i.i(!r .1 Chnflcr I ('onnN"ing *iih S(rion 7000) 'l l)iri\i{rn l
<br />of rhc Ausircss md Profcssions ('odc. rnd mylicctr* h in lollnr(i clfr.r'
<br />Li.cn\c Ntr'nbcr
<br />C(INSTRtJ(]TIlTN LENDIN(; A(:EN(:\'
<br />I hcruhy rffirm u dd FnrlrrofFrluty rhlr rhcrc is r.. {rrucrion k'di.! r3'rc, ntr tk lrrt'nnitrcc oflhc aork for qhi'h d1t Frnil h
<br />i\rucd (s(.3097.civ. c )
<br />t trdcisNrtrt:
<br />---r. .i\ Addrc*
<br />rt$\c Df,nrirrcd nmncny ntr in\t)cclio,ttr 'Y* -",,"D6:A /!,\ppli(anl or A*enl signotuN:Auitub Br:IA^,Ot
<br />Flood Zone Cefiif .
<br />I hcrhv allirm undcr Enrhy ol pcrFry rhd I m cxcmnl tn,nr rhc Conrt!.bn Liccnse liw Ior rhc iollowirS rrs)i rs" 7011 5
<br />ausiness a'rd Profcssinn Codc) trv Cily or Cornrv whi.h rcqutcr a Pcanir ro co dru'r. ahd nnlrovc' dcRrli\h ot RBi anv
<br />ntucfurc.p.orbil\ issnrft c. ilso rcquir\ rhc ilJflicrtrl nn $.h Nnnir lo lilc r \ r8tr1{ nrlcmnr rhal hc or fic i\ ltTnsqi FtrBUln
<br />h lhc p(*isn $ of lhc Contacrois Li.cntd La* (ChaPrer 9. ConmcncinB wirh Scclion ?flD ot Divrsion :r 'frh' Burinc\! rnd
<br />Pr.fcr"iotr"Codc)orlh l[or shc is.rtnD hcrcfronrandrh.bd\n lor lhcrlLlcdcxcnPrnri nyvi'lari'nofSc'lion70ll5nyatrv'
<br />aprlicitrlior rrmir \u$lccrslhc {plicrnl ro rcivilPcnrlryolnor nnn.rhdn ivc hundtd dullar (Stl)o)
<br />A.D
<br />C!-Sd .vm ol rhc pmE d y, or my cmployccs qirh qrscs !s rh.n $h conrP'n\rtar. will d{) rhc work ffil rhc itrt'rt' t nor
<br />imnac,l or ollcrca rii sarc r !e 71Md Businc$ and ti,fc$nnr{ Codc 't h. G,nlhcr(tr \ Li"n{ Law doc\ n'r rrllv k' sn 'wtrcr
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<br />Ihc pmpcny who ltrrilds ot i'qtro!.* rhcB,n- lnl who d,rs srtch sorl him\.lfor hcr\clfor rhro!8h hi\ o' hcr ownc'nnkJyccs'
<br />p,"'ia"a rrror *r.t i'npmvcftirs rrc nor inre'dcd d oficr.d tor sk li h.*cr. dr tuildin! or imPfl'trmnl is n)ld wirhir 'nc ,cu
<br />;f.o rLji({r. ,hc ()*n;r Buiklcr*ill h.!c ttE hurdcn.lpovi're rh hcorshcdid 'nr buikl.r inlmrcrhc pmr'n, ior tlr Nq$s ol'
<br />l.isouncrofthcF)!cny.!ncr.lusivclyconrrrcrin8sirhlicctr\c.l.otrlr{kn\r{)"fslrucrlhcPnrP'r(Scc TOT BU\incs
<br />*r n rr"""n Cn,t",tt t
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<br />C,,ntu.rois Liccisd l-aw docs nor lprly k, rn owncr ofpn)Nnv eho htilds or itnnr'vc( rhcrc'n
<br />id who conlErrs f(r such ts,jccrc silh I Conrtrro(\ ) lt.n{rl Pu^urnr ro rhc Cofi(ttr s Liccns l nw )
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<br />APIIICANLDECLAXAIPN
<br />t trtby nfitm und.r lcnalr] ol Pcrjury onc ofrhe rtnk,wine dcclaro'ions
<br />Dcixniion Pcflnih Asb.ios Norifi.drnrn Fcdcml RcsrLrn N (Tillc40 PndO
<br />-RcqDncdbrtcrolNorift
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<br />I ccnifylhar rhc Ldcral rccllnrions rc8ar,irg trslf,nos rcnnrvrl rrc ior indi'ahlc ro lhis ltoFlr
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