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BUILDING. INSPECTOR RECOBD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUIt,T'ER DFJI,CARATTON
<br />l hcrcby,finn un'lcr i'cnilly of pc0lry rtrr I anrcr.mfl rfln rhc (onrnclos l-iccnsc l,as turhc r(rk,wnrS rc$on (S$?011.5
<br />Busim$ uNl ftolassn'n G c) Ant Ciry or outrry shi.h rcqutc( a lcrmil ro con{tucr, drLY. inProvc. d.'mlhh nr rcIBn Jny
<br />(tucrurc. prior ro irs isuai.c, alv, nqutcs thc,Iplicinl tursuch pcni b ntu I \igncd {ntnrnt lhd h.or ihc c li.ctrsd puisuinl
<br />n, rhc fl.vsions.frhc Conkrcrors t.iccnscd Lrs (Ch+r( 9. Connncnci,r8 *irh Sccrion 7Un of Dilision I of lhe Busincs and
<br />Pmltsions Codc) or lhar ts or shL k .rcmpr rh.rcioin Md lhc bn{h lnr rhc 0llcsd .rc'npr i,In. Any viohlion oiSNri,n ?0.11 5 hy,ny
<br />lrllicotrr nx apcnnir suhjc.ii rhc {plicnnl lo !.ivilncnalryoinor nnncrhri livc hundrcddollm (55UJr.
<br />l.r\oLvncr.lrhcpnipcny.o nycmpbycc\wirhssEc{rsltunsohcotrDcnsrrioi.silldodicsorkdxlthcsltrrutis,
<br />iNcrdcd or ollcrcd rbr sL l se 7(l1-r. Btrsinc$ n d F\oL$iotrs Codcr l hc Conrrdor's Liccn( tr! does nor lprtly ro an owtur .i
<br />rh. ptuI.dy qh(Jhoildsor iqmrcslhcNn. and *tn d{xs such *o* hnn\clfor hcr{llorlhmuglrhilorh.r ostrcn1Pl.}tcs.
<br />nmvidcd rhrt such i'npnrsrnrs rr nnt inrcML\l oi .(cton n, rD. Ii howcv.r, rhc huiunls or i prorqrc is hld 'irhin orc ,tr
<br />of conlPLri(r, rhc Owncr Bxild$ qill h$r rhc tdrd.n ol Dmvi.s rhf,r hc or \h. dil ft{ buikl or im0olt tlr lrpcny li, rh. puqxM of
<br />Lnsostrcr.trhc[opcny-an]gcld\ntlyconr inE *irh h..n\cd co rcktr\k,con('u.rrlFfn)iccllss.7($4.lllnncss
<br />rtrd ltrl6rion (, e:'Ihr C.nrirktr s l-i(nsc LN do.\ tr.r rfflyr) d.orvtr.rnlPR)Nnywh() buil&or i Prcrs rh.rcon.
<br />rnd ;ho c.ik!cr\ {r, ru.h projcc$ wirh rCoftrncrrl\) li.cn\d pursur i hrhcConrrttr\ l,i.ctr{ Lf,s)
<br />I rflcrcnfr utrd$Scclio.-. a &PC ftrrhirlcrvrn
<br />tlal€ O*n.r
<br />woR(En.S. CON|p[.NSA,fl ()N
<br />IIEIIAAtrIION
<br />I hc!.hyaifilnundspcnrlryorFrjuryoncolthchlhwirslcclr n,ns
<br />IhNr ,.lEillruinrrinaCcnificd.ofC{nr*irroscll lnsurcf{trwotkcn.omp.n\arn,n,r\ PrcvidcdlorbySc.rn,n]Tmolrh.
<br />I-sh,r Anb. forlhc pcrf(trnEncc ollhc sork irtr which rhc p$nrir ir issucd
<br />lhnvc rnd *illmrinrrnr ror*$r .omncns iotr insurrncc. !s rcqln.d h, sccr ion 1700.1'rhc Llhor C,nlc- tur rhc NlfonnMc ol
<br />lhc wori nn *hichlnisp.mii 1s is\*d. Myworkcn comDcnn,li,)n inst rxn.t .aft{r nM policy numbcr uc
<br />I ..nift Ih r i rhc lf,rlonnrocc oflhc *ork r(n shirh rhi\ pcrrnir is nqrcd. I \h!ll tror ca]ph,y atry Pcnon i. m, Nnncr
<br />s r$ to bcconE subFcr h I hc $orkdri.omp.n$t bn lnws ol Crlilbrniund agd rhd if I should bEoN bicdt,rh.
<br />workcri comncnllr ioo pi{,!nbh of s(lion 3700 of rhc Lahtr codc. I \hJll, hnhsirh conDly *irh rho* !nrvisi(,.s
<br />WARNING l;iilurc ro rcurc workc .omFns on covcrr8c 1\ unluwiul. rnd \hrll subjccr m carPloycr b fininal timlrics.trd
<br />civil finc\ u! lo onc hundrcJ rhouund d.llos (SI(x).[](x)). irr iuldiliu k, rhc.o{.f.omPcnerion- dJro3c\ as ri.vidcd f.r lhc
<br />Ssrior.10T6 oirhc lntxrCodc. Lncr( d d ronEy r |c.s.
<br />Drle: Applimnl:
<br />r (:FNSID (:(|aiTi,{CTOR
<br />DLCI.AEAIION
<br />I hcrcby,rfirn xnd$ pctrilty.lF,jwr rhal I uu liccns.d rtulcr Pr.vision olCh0lrcr 9lconnttuing wirh scdnrtr 7Ol)0) olDivi\n,n:l
<br />of thc Buircs uid Prcrc$ons Codc. lnd my liccnsc ir ir tull lore u cn cr.
<br />l-i..i\c Chss:-
<br />caN f,lcuqNllxlllNlillillLr
<br />I hcrci,y rlfi,BUnJr p.nrlry or,)crjrry rlul th..c is a.r'n\Iru.1i(n, lcndirs atcncy ior lhc Pcrturutut orrh. work lor whi.h lhis Pcnnir il
<br />issucd (Scc lo9?. Civ C )
<br />l-ctulcr'\ Nrnr
<br />-
<br />l-ctrdcr'( AdLlrcs _
<br />6ITUCANLDES,AM.IIAN
<br />I My !flimr u ndcr pcnnlry or trr.Jury onc ol rhe followin8 dcclaruiion\:
<br />Dcndiliotr Pcrnrih A\bc\ro\ Norifi.n(bn Fcdctrl RcAul i(,rs(rib,lo. Pd6)
<br />-Rcqutcd
<br />Lcrlcrof Norifi ctrri,n
<br />lc.nifyrhnr rhc rcd.flrlrcSuhrions rcgmling rsif,nos rrnn)vrl rr. or rt,!licrhlc brhir pmjccr
<br />I ccniiiih lhrvc rc rhis applicrrbn,nd {d.rhdrrhcrh,vc itrtuflnrri{r i\.otrc.r LBrLi n, coryly r irh all Cky nnd County
<br />ord,nrrccs Md Strrc t wsrclalin[rohriunrg.onsid..otr.aMhcrcb!3urtxtri.crcprc\cnrdivcsofrhisCityrtrdCnuniyr.cnrcur.nttr
<br />rh,!c nf, rion.d !r.tDly io. ir\l,cclion purpo\c\
<br />ADpliGnl.r,\!.nl SiBntrlure
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil.
<br />FINAL X/7,2/ty' ...-,
<br />Certilicate of Occu n
<br />Notes, Remarks, Etc
<br />Erection Pads
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