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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE COMMENTS I'W\},R BT II,Df,R DFI,('AR{TIO\
<br />I hcrchy o,lirm utucr ncn.'lry nf pcrjur) rlrr I dn crcnpr fft,ft rh. G,nad.^ Lkcnsc lrw for ric lirllowin8 rc.nrn (Sc.70ll5
<br />Bu\i"r* ,tr,i Pu,tusion C,\lc) An, Cir) or Coutrr, shich rlllncs a rErnrn ro con(rucr. olrcr. irlrovc, dcnolnh or rctrn any
<br />!rurrurc, | .r rn \ ^sdrn!r.0lso Ntutr srhr3[rnl'!r tu su.h pcmir t, filt r siSrd surcmnl lhlr tE or \hc i\ li.cn\cd tur$lnl
<br />r' rhc nnntinns .r rhc Cnnlrd tr'\ LiccneJ LJw lChrplcr 9. ConrnErcinS wilh Scclion 7O0O of Dilhion 3 or 'hc Burin.s xnd
<br />Pr,rc{i,,n\ C'dci,tr rhor hc,tr\hc nc\cmnr rhcrcrromrnd lhcl,aris tor thc alL-qcd excnDtion. AnyviolllionolSecri,n?03l5hyony
<br />/?t!,di{.fan {bJ.\r.rhc Jrfl'.rnrt,J.'u'l|caotvdnnrm'crhMfi!chundNdiilh,\'95rn'
<br />( L/^ .",*, , u'. r ,*d j. or my c'nrirL,rc.\ r n h wrscs is rhctr $k conrFnsnrion. wir do rhc {o.k a rhcsr*ru,ch trn
<br />,inrcndcd ur.llcrcd r{ $h tscr 7LXl. tsu trc$ rid ftufcrsi{,ns Cot: Thc Cont&ktr r l-i.cn\c k} d.cs not spply ro si .qtur of
<br />rh.In,Fny sho nuiB\ or inr{m\$ rhcmn. ind qh. des skh eork himrlfor hcsclfor (hou8lr his or h.r own.n{btccs.
<br />nnrir(d rhrr\d(h imrI ^cmnr\ rrc nur inrcndcd nr orlcrcd for {h. t( lD"qcr. rlEhuiUiryor nn0mvcm hsldwirhinom}tr
<br />.r'.nl'1lrlclrtrrtrO{rrBtr'tr.r{illhJK,hrhurdcn,,fnovin8rharh(or\hrtlr.l n hoitt !r inErrr rh- pn)fcny aor dr plrF,{ of
<br />-1.
<br />!\ owmr oihc Profdry. rtrn .r.hrnrly .ontrrinB wir h li.cns.d rontr.ri'n iJ .on(tu.r irr,n,icr (S( 7Or]- Bunnc\r
<br />xnd Plofc\si Codc.1hc Conrracrois l-iccnr L!$ doc\ trol rntlyk) itrowrcr.lnropcnywh') build\ or nnp(^cs rhcrcon.
<br />{nd qhu.onrm.rrnrsu.hpnl]tcr\wirhaCofirttrG)liccnscdpu^ur n,rhcConrrcttrsljccnEl!*r.
<br />lr cxc pruid.. Scrron .R &PC larrhisrcrv,n
<br />|ft,"," u/t/r/ y,,
<br />DLCI,ISAIION
<br />I h.rch) llimunrlcr Fnrhyollcrjuryotrc ofrhc loll.sd! drclrrari("r\
<br />-l
<br />hrtc nfrl qill nMinh$ ! Ccnific.tc of C.ns. b S.lf lnsrrs,ar workc^ lrnnpci\arnnr. r\ pmlidcd tur l,y Ser i{{ .17(X) ol rhc
<br />tih.r C:{nlc. Li rhc lrdontuncc ofrhc work tu shi.h rhc pcrnril is isud
<br />-l hnlc ond *illnlinrain worker'cotrrpcnsation insumn.., as to\tutcd bysccrio.l?troolthc Uhor Cbdc,lor rhc pcrfor rmn.c or
<br />lh. work lor whth rhh pcrnril is hsucd. My sortcs conr!..slrion insuDne .nhr kl lrlicy numb.r dc
<br />Poli.\ \u'nh{. _ H\nm,
<br />:jz,/r(nrry rhd m rh. If,rr rnurkr urrhc work ntr sh'rh rhi\ Frmlr n nso.d. I rhrll nor cmtk,J, any p.rson in aiy mrnncr7 i ' A I' hd,m uhj(r ro rhc q nrlc6 (nrFnslFtr hws of caliLrni.. Md ,8rcc rhar if I should hi-.onr subjccr ro rrr
<br />trorkcr' coarpcns n,n previ\ion\ oI Sdn'n 37m ol rhc tjhtr Codc. I sl$ll, lonhwilh mmply wilh thor pBvnions
<br />WARNIN(;: Faihh ro $.urc sorrch coml.nsrior covcmsc is unllwlul. und shrll suhJcct !n cmpk'rr to crininrlpc rltics and
<br />civir fitrcs up k' oic hundrca rh.xsan dollrs (3lOO.ONr. ir lddilbn k, tnc cosr ol conrpcnsltion. dlmrs$ as previdcd l'or rhc
<br />sNrl,r 3076o1rhc l.rl!r (dlt id(r.n nlrr(tr).!\lo.s,t/,.,,,," b /7 //y W,* -r-F/I U r t('t Nrfl' ('i,l,t4(( LR
<br />DICI,A.IAIION
<br />I h.rchy !finm undcr pcD.ltr.fpcrjuryrtu I im li.cn*l und.r lr,,vnioi ofChrprcr 9 (.unnftn.'ng wirh Seri.n 7(X[) ofDivhiir:]
<br />ol rhc Bu\im\{ and Prof.\\i(,n! Cod.,0nl nry liccn{ i\ in full fircc ud cttarl
<br />IATSIruJIIIONI.INDINIj-II1i$TII
<br />i(u.d (Sr( 1097. Ci! C )
<br />A.TTUCAIIDICIdAAIION
<br />I hddry allim lnder pcnallyrfp€rjury onc ollh. iollouin8 dal.rations:
<br />Dcmlition Pcflnih.Ash.(os Notinc ion Fcdca, Rcgul io.s{Tirld 40. Pd6)
<br />-Rcquned
<br />Lcncr olNoriarcrtion
<br />-l
<br />ccnily rhar rhc rcdcrol agularions rsdditrs astEstor rcmvaldc nor +pli.,blc ro tht lmidr4
<br />:,,lEJ.cnrty rhxr lh u rcrd rhh arpr'.a,n'n inJ nJrcrhr rhe ahov. iDlorrorion iscorccr l3srarocomplysnhtrllCiryandCoonr,
<br />Gaitranlc(rndsrrt.tjeiftbr'ner.hd'Urng..ni.'ion.adlhcrcbyrurhorir!ar..snrdiiv.s.rrhi\Cirydndc.unryrocnr.rxF,!rhe
<br />$i,vc nrnrioncd px,txdr- f{n in\pccri{)n purporc\
<br />\q,pri.,.r ".,rg*r si,'*u*
<br />3"- .r .,-e (prinr):-4*Je/€fue4t5 ),.,
<br />412/r?
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/Vent/l nsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Frami ng
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Itilasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL t-LL- t6 JA.t -+,T1-
<br />Certificate of Occu pancy
<br />ID/SIG.
<br />Notes, Remarks, Etc.
<br />Li.cn* Clts:-Licc.s. Numb..
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<br />Drle conlr.cror
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