|
BUILDING- INSPECTOR HECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS (,WNER 8T]It,DT]R Dr]l-CARATION
<br />I hcrchy rffirm undcr p.nrlry {)l Frjxry thar I d cr.npr rn,'n rhc cirtrti.lor Liccnr l,w lnr rhc t,ll('wine r.ae,n 1Sc..70115
<br />Busincs a l Potds\i{'. Cud.): Ahy Ciry or Coutrry shrh rcquncs r Fnnir ro $nnrucr. rlrcr. improvc. d.trblish or apar y
<br />\r crurc. pri{trn, ih i\uimc. ilro rcquias lhc nrpli.Ml r.r \u.h lEflnir lo lllca \isnsl {dcnFnr rhar lf,o. shc is liccnscd ,)unu.n!
<br />tu rhc Drovnions ol rhc Conlrackn \ Liccnrd ll* rchapicr 9. Commiciig wirh Scction ?0t{) of Divnion I of rh. Bu\incs an'l
<br />Ptr,fcsionr Cod.)orrhar lEor\hc is cx.mpr rhcrcfonand rhcblst l'or thc rllcgcd cicnrflion Anyvn,hrirnofScdionT0:ll 5hyrny
<br />ipptRant for ! Frmn suhr(r rlr ltplicant ro !cirilpcnrlryofnor nxre rhM fivc hundrcd d.llar lS50O
<br />l. i\ .*trcrol rhc 8)!cny. or nry enr!Lycc\ uirh $nSc\{\ lhcir s1c.onrp.nun,n. willdo rh. work el itE ntrrN i\ nor
<br />inrcndcd.rollcre!irelc(SN7Ol4,Bo\itu\\mdPnndsionsGrlcThcCtnrr0cto*l,iccnscl,rsdocsnoratplyt'rd.wioof
<br />rhcpmFny whl huilds or iqro\rs rhcmn. an l who d@s such sl himrcllorhr^.lforrhn)u8hhi\othcrownc'.pbytcs.
<br />polidcd rhrr \uch impmlmrihmnn inr.'rLt uDltar.d for sak ll Inrw$cr. rh. tioildinA or ir{nrvcN ny,Uwihinorc,!d
<br />of.omtLrFn. rh. O*rcr atridcr willhorc rtE hurdcn ol FovinS rhJl hc or \hc did frn horll or iDPrort lhc lrepcny nr rhc l)urln{ of
<br />_1.8o*ncrolrhcpmpcny-rmcr.lu\ivclycontnrin8sirhlirci{d..nrd.lrtrsr.con(ruclrtEpn,jccr(Scc7I}.r{,Bt\inr\\
<br />a BitusnnCodc: ThcConrrrclors Liccnsc t-r* doc\ norrlplynr anoqncr ol tnrF y$ho huildi.r i'npmvc\ rhcrcon.
<br />rnd sho conrrcr\ror (uchrbjc.rswrhr crtrtrrcttrls) liccn$d pur!'!nr k,rhrCoikrrt, \ Lmnsc uw)
<br />lrnr\rtrrnrun(l.r S.cr
<br />Drt.: ()*n€r:
<br />wonxr ns' c trru pl-ls,rrtou
<br />IIEI;LA&IIIIJN
<br />I her.hy fl n oidrr F- rlry ol lcrjury onc of lhc iolloums dcclnaiion\
<br />-l
<br />Mvc url rillroi'rraii r Crnific cofC.is$rk,Sclfli\urctuq.rkcrrconrp.lslrion.rs lr,,vidcd nn hl Sc.rio.lT00 olrhc
<br />bhor Codc. for thc pcdonMrcc oI rhc sod ntr *hich ihc pftnir n n\ucd
<br />I hrvr rnd willnridrd q.rkcr\- con{'tnnrtion iNur!trcc. n\ rcquircd h}Sc.rion 17(D.frhc tih.r Q)dc. iorrhePc nnwccol
<br />rhc work n, $hi.hthN pcnnil is issmd My $o.kcr' cotrrFnstiotr in\urJncccrdrr r d Nli.yiutr$.r rc
<br />a,{u t/tt at0rhtr 1/C c.ta. o&3 /o x,1)v
<br />l.crr'lyrhI i0 rhc pcnrnndmcofrhc sqk rhru'hi.h rhis n nnir i\ '\\dcd.l nrlln.r cmpkJyany Fr6of if rnynunncr
<br />v, r\n'hcNnr \ubF.r t,rhcso'tcr\ c.'nfi\nri( lis( .l Crlilrm'r. und i3rcc rh3( if I sh'ukl }tco r \u\..r tu lh.
<br />workc^ $n,Fnuri,,n lovA b s .f Scdion :17(x) of rhc t-ah, Gdc. l \hrlL. f{nrh*irh co ,t]t *irh rh,{ fov$hn\.
<br />WARNIN(;: Iiilurc ki cclrc workcn com|xD\ari, corrrrgr i\ uih*tu|. rtrd \hrll {rhF.r lrr cnrrl(,)ar h oi'ninrllrnrlrN an
<br />. \il liN\ nf t,, on. hnDrlrct! rln\xtr,| (lolr'\ ((lllr.rrxr)rtidirnnr 1r rh. r,^r fl ..rt*r\rri,tr,. ,htr grs n\ t(riJrtl ntr th.
<br />Sccliotr 3076 ofrhc tihor Codc. inlcrc
<br />*". y(saL{
<br />I hercl'ylrfirm undcr r.nalryorn rjuryrhar I !m liccnql undq Fovni.tr olChaprcr 9 (com'ftmin8 sirh s(rion 70(xJ) oiDivision l
<br />oi rhc Ausine$lnd Profc$ion\Codd. rnd ny li..n* i! ir rull ror.o<{ cfi{lI b-e 33 t
<br />"",.
<br />. s- llaltS
<br />grlsBllgloNlEaDAliaclNqx
<br />I ficrchy atfin. uMcr pcnahyofr.rjxry rhar rhnc is acon{tu.rion Ltrdin8 68cmy li,rrhc pcrforromc of rh. work for shichihis Pcnnit h
<br />nsucdrs( 109?. civ c )
<br />hnCcr. {.mc
<br />-
<br />AIILICANTIJDCIABAIIg]!
<br />I llrhy lnnmundd r.nnlry orp.r)ury orc oflhc follosrB dslnlIions:
<br />DcnFlilion Pcrnrits Asbc*x Norilictrrio. Frdcrnl R.guhrnnr\ (Tnlc.l1). Pnn6)
<br />-Rcqutcd
<br />t rrcrof Mlindirn
<br />_l rcn
<br />'fy
<br />rhnr rh. fcd$al rcgulnrions rcE din!0sbc{.src nlrl arc nor rpl'liuhfu t) rhn l)n'r..r
<br />Iccdilylh lh crc thnaplliclrn,n:u {rrcrhrirhcxhnriil,nnuri([a.on.r llarLrloconrlly$iihr]1(iryrnd(-outrry
<br />ordnrn.c\ rl Strlc tn*r rcldin8 x)il(li',g.onnrudtrn,.rtr{lh.r.hr" rhrvcr.trc\ctrkrrc\.frhn(iryxn(l(',,!trrvroc r.ru rdk
<br />r}i,rc nEtrri(,ncd pn,pcdy for nr
<br />\ppln)n or,\!$t sixn ltrrc
<br />^*'lf*Q_
<br />G^ g;pj;
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Rool Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lalh
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />-r t /)-
<br />FINAL t ,l't/Dfxn.,rt *z-/
<br />Certificate of Occu a
<br />Notes, Remarks, Etc.
<br />>,' ?" h
|