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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS O!T'NER D TIII,DT:R DEI-('ARATION
<br />I hcrcby l,lirm unicr prmlry (if F!u.y rhd I anr c\c'npr fro'n rh. (,nr0clos l,tcn.c Lnw f rhc l'olk,*ing rcis.tr lS(70.115
<br />tlu\inc\s xl Prnt*i (txlcl Any Ciry or (j,unry shich lcquirc\ a Pcrnnr n) .on(ru.I. alrcr. inl,ntrt. d.oFlish r r.rrJn Jny
<br />{fl.rurc. prir ro i\ isnan(. rlnJ rcqunc\ ihc a,'plicitrl f{tr \uch F-rnnr hr iilc a signcd ddc'rc rhoi h..r ihc is li.ctrtd ,'trNuanr
<br />ro rhr lruvi\nn of rlE Conlracr,tr\ Li.cn\dd trw (Chal,rcr 9. C.mnrcncir8 wilh Scclbn 7(tx) or Druision ]l of rhe Btr\i'r( rnd
<br />Pn,l.s\n,tr\Codcrorthrl hc or \hc i\ ckmfl rhciclionrtrd rhc hr!i\ for rhcrllcScd cicmpri,h Any viol.rionoiSccri,n 70:ll5 by!ny
<br />lptli..nr hrnncrarlr ehjc.r\rh. rpph.anr lo {civil$mhyor oi nxrrcrhrn r'ivc hlndr.d dolh (Js(x))
<br />I. ar owkr of rhc DnrrEn y. or my .nfk,y.cs wirh wn8cs a\ I hcn qrb ctnrl.Nar ion. $ill do rh. solk .nl thc {rrm h n.r
<br />i cdcd oroilcrc(lf{nel.(sd?01-,l,Busirrsan{,frcic\\i,n!(ixlcThcC. rr.r{n\Lkcn{cL0{de\noraltlyr.m.wncroi
<br />rhc pn)pcn, wlx, t{ilds or in!'Drcs rhcE,n, and whr d,8 luh *. him\clforhcscliorthoughhi\o'h*nqncmPlovccr.
<br />pn,vidcd rhrr\uch impn'vctun(irc mr ilcnlcd oroltircJ l{tr srk lt hoscts. rhe huiklin! or nlll,nN.,nnr hv,U wirhin.nc Jtr
<br />otmnnkrion. rh. oqmr Buildcr willh{v. rh. hud.n olpovirr! lhd tE or \hr dil mr hoitl.r inrPr.lt rh. PolEnv for rh. I,Uqst ol
<br />Lrs.strcr.lrhcnoncny rn1ck lurirc l, contm.ling wirh lictn*d .(,ihrcttr\ !o Nnndd rli n(,id ( S.c 'l(!l Bu\i'k$
<br />rM l\l)fcsi.nCodc'rh.cont,cloirLiccrscla*{l(rsnnrtmlrn,anowncrolflor(nywnohlild\orinryovcsrhcrcon.
<br />rnJ whu .onnichlor such lroFr\ *irh a Coitr{.to( s I li.cnscd lurudrhrhc Conrrlcroi\ Li.c.rc tis)
<br />I r r.\ctrU u cr Sccrn,
<br />D.r.: Orn.l
<br />woRxaRs'(:()MPENsA'rloN
<br />IJECIAMITON
<br />I hrrcby afirm undcr ncElryorp.rruryom olrhc lolli,!inE dNlnrdrnrn!
<br />I hrvc md {ill minlain a Cenifkar. orCon{nl l. Sclf-ln\urc li, sor*6s corn ensuiio.. a! provdcd ior bv Seiion l?00 ofltu
<br />Iltxtr Gic, r{, rh. p.rorroncc ofrhc *o tnr qhich rhc Pclrnir is ksucd.
<br />I hrlc anl willnrinrri'r sorkci{.onfcn\arn,n in\dra.cc. rs rL\lunci hyScciion ]?(Xrofrh.lihorC{ic. for thc lqlonumc of
<br />lhc Inrt lorthichrhn Pcmir is issmd My Norkc^ .o ilc.larn,n insuran.c .xdtr .M Frlicynumh.rd.
<br />I No. Cuo*J
<br />5E trjC nn so l\
<br />-l
<br />c.n'fy rhI in rh. Nrlirmorcc ofrhc work n, {hi.h lhi\ pcrmir i\ i\\urd. I rhall nor .'nplot dtry tl.ro. in lnv nrnncr
<br />q, $ h tconr suhjccr ro rh. *.rkcn' co n{rnsor ion hws ofCnlilnrnir' ui !3N rhar il I ihould hccom \rhJt.r k)rhc
<br />worko r' on]Pcnvrion pmv$n,ns of S6rhn .l7m of rhc trhtr Clxl.. I \h!ll. fi,nhwirh conlPlv $irh rbY Pn,vhion\
<br />WARNIN(;: t_Ilurc to surc *orkcB .DnItn{dn'n corcnSc is unhtrful. aftl xhall suhjccr rn.'ryk,vcr lo ominal frMlras.nd
<br />.iril liics up h otrc humlrcd rh.u{nd doll&s rslo}.(rx)r. i'r sddirion o rhc cn( ofcr
<br />h\
<br />".J4
<br />Ll
<br />I hcrchyrfiir u crnrtrxlrydlpcrirtrrrhrr I n li(n\(lundrr Pr.in.n.l('hrrrrr 9l.oinNrtr i,r! \ h S.rrtrrr rlrx)) ol l)n \,tr' I
<br />,)r rh. Bu\i'Ncs Prorisi(,N Codc..id nrv liccn
<br />,ic.\ccass vk c-rc
<br />sc is in flll t6.N dld cilsr
<br />=a!p
<br />CONSTRI(:TI(IN LANDING /l(iFNCY
<br />I h.rchy rrfirm u d.r lf,tr.ltyoll).rruryrhsr rh.rc k..otrnrudhn hnding s8c..y for rhc pcrlorm.rc ofrhc qor[ for whth rhi{ irtmil i\
<br />is\ucd (ss.:109?. ci! c )
<br />lfELlCANfltllLLBAIIO!
<br />llxnhy afinmtfrhr nLnrlry ol pcrjry onc orrhc tull(,*ir! dc.hnli,,n\
<br />D.nniriotr Pcirnir\ A\lE{o\ Norifi.aLun }tdcril llcBulari,n ('lirlc.l0. Prn6r
<br />Rcqutcd t.rrcr ol Norilkrri,rr
<br />l.drlirhd rhc ttdcrrl rclrl n)ns rc8.rdirg !\t!{or rcmvrl rrc hr lptlicrhlc n, rhn ltul$t
<br />rhi t hrr rcnd thi{rt,rlicxri{)n, l {d. rhxrrhcrhic irrionnrrion i\.(ic.r IrIrNh.o'nlly*irhollCnvrndCou y
<br />,, (|tr,,tr,..\ rnn Srrrc l.Js\ r.]Iirg nl
<br />rtr,r. r rt{rc(lnr)Ndy f{tr nrJr
<br />ApDlirotrl D. Aaot Sit.Elu
<br />Cily dnd Counryr..nrd uFn th.
<br />",.$t/st
<br />Set Backs
<br />Forms/Sleel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulationi Enerqy
<br />Drywall
<br />Exl./lnt. Lath
<br />Brown Coat
<br />It/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Beq
<br />Deputy Final Report
<br />Enqineer Final Beport
<br />I ,,,1
<br />FINAL --z/7/*)2' t Wtit/
<br />Certificate ol Occupincy z/ /
<br />Notes, Remarks, Etc
<br />Erection Pads
<br />Flood Zone Certil.
<br />A /z>/zo
<br />Sc.!.i 1076 of thc titnr(iic. i' .r.{ ind .nEy (
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