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<br />BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNEN BUTLDER DELCAR TION
<br />I hcrcby r[ir6 und.r Fnilrt or l.qury lhar I fl crchpt fmn rlE (:onlr4r(,F l,iccrs liw rot rtE folh*itr3 rclsn {sE tu.11.5
<br />Buem$ .!n Prorclri,n Cdc, Any Cilt or Cir,ry f,nah EnuiB . Fni r. .!nr 1. !lta. irglmtc. d.mrkh or Ep.n .n,
<br />{MtE. prnh nr issuuc. !t$ r{urc. rlE +Pli4r torskhFad to nb! si8En rdcmnr rhtl ltor.tE 6llen€J Pll.ut
<br />16 th. F.ririmr or rE Conrtrr '. La.rcd l,w lchapler 9. Conrmtin! wnh s.crion ,fiD ol Divirirn :l ol rrE Bulim( d
<br />hnf.i\ionrcrdcI rhir horrh. ncx.,ry LrEr.6oi rdl rh. htsii rd rh. .lk8.i .rcqran Ary ti,hri'n of sdbn Tol l th,lny
<br />spplic{nr r rFmirtuhr.rslh. rFpli..nl lo o .ivil p.Mlty or mr en rtun filc huftit d dollss($50o)
<br />-1.
<br />u\ o*tr.rof rh. ,'oltny, or nry rnrrryEs r h*!!!r!s rh.ir $lc cotrvr.srion, willdo rh. mlt.rn rlE sttElE il m,l
<br />id.rLd of.En ni rh (Sa 7(pr. BuriEs .nd Pn,r.(i'B C.iL TlE cl,nrdm r Li.tn€ lj* dxs rr {?lt 'n
<br />m owE or
<br />rfi. F,Fny whrl ilt! or mImE! rtEB)tr en eb d(B sh x,ri hinrlf or hcmltor rhmugh hn d lE, o*..itlbF.i
<br />,ovit d rhll ruh imlmEtur r E mr il diilcJ d .rLEd for {b ll h,{rE. rlE hoildins or inpt8cnt ar sld winin om yr
<br />oaoq*ibtr rtr OIG Aut.r lill lrE E h,&nof Fovil{ lld lEm{t dil.d lliB 6 iqmE dE FFry fG l,t IEF*ot
<br />l. r\ osmr of rh. ,lop.n y. m cr.lulEly co.texns $rrh lKin*d conrdo6 to (,r$ruct rlt FrFl ( Se 7ly,l. BNr*ri
<br />md thtsir Co& 'rhc (bnt,cktr ! Li..n€ lrw dcr mr lnlly to rn oeoct nf ror.ny who build! or iBl,rovct rhc..on.
<br />dd rho s.rtu1r fG rkhF,Frls * h.O'nrrEionn lFnrd ll0^d hrlt G'dtur'r Licns L.*)
<br />I !d.r.m.r uEt<. Sdr-n
<br />l)rrr
<br />)llrllilBf.lauu:$,ularlr[!LI3 11L]I
<br />Ihd.nr rrltr Under Ftrrlr\ 'n F'Itrv'ir ofrh! nnk,trn! d..[,, trtr\
<br />-l
<br />hrE r l will nEi.lrin r C.nificsrr of Consnr lo S.la lnturc tn woA.s omFnrdion, .r In vidcd fot by S..hn :ulD ol lh.
<br />lllxtr C.d.. fd rlt Frrffi olrlE Ert fd Dnin lll Fnn k kcd
<br />-lLenily
<br />rhrr in rhc Frli,rm*. orrh. work ritr whth rhn Frmil n n\sd. I \hsll no'.n'Pby iny p€r(,n in any 'tutur$ { b hcr,m rubFr b tlE *o.lsi o'riEn\rtbn h* ofcrlifomir. rld .aN thd f I rhuld tE(E snhf( t, rtE
<br />*o.k.n' L\nncnslt nn pmvision\ ol S(ri{'n 170) ol rh. lrrr C,xl.. I drll, n'nt*iri conq'ly *irh rtn* ln,vi(io.(
<br />WARNINC Fsilu( t, du. rorlcu .nnrpcn{tion (r'r.ms. ir unL*luL ! r rh3ll ohjftr r..rrploFr ro dnirol FtuLi5 r.d
<br />h nft.hnfrlrnl rtr)reil drlla'\ r!lurllx)r n,
<br />trfurc( rnl oirt s n.\
<br />f t,opr-,nr
<br />tf,nrlrt.l p.',,try rhrr I Jn' I rn)vAi( "f('hr|rciqr.oNrr,f,itr! wirhSNri)tr7(xr)rolI)Nieo .l
<br />|f llr Rnlrs rlPnlf.(k,n\(ix,. arl mt
<br />I h.rrl'y urll'n un(l.r Fnrlrvol p.rjury rhnr I {rucr( kRln! r3.N} ntr r[. trrlortruN. ol rlt *rrk lr, qh(h r[N IlInnr N
<br />rrkd(S( :t(87. Civ. C )
<br />Lad.r's Nstu:
<br />knLr's Ad'lE{s:
<br />-AI2LIIAILIIE(I.AS{IIAX
<br />I tln'hy.tur uklcr p-nalryofp.iJury om ofrhc tulk,si'rg dccludrn,ns
<br />Dcmrlian lomk A\h.nor uonrErrion llnci,l R.EULrhns rTilbr0. Pd6)
<br />RcqurFd tr .r oi lit{lrkarin
<br />_l (cnilyrhi rh. r'L{rrul atulrri()n\ Etdnr8 r.tr{o\ rcnhvrl ar. norlppli.lhlc n) rhi\ l ),(tl
<br />lr\rr',yrhrr llr\.rc lrhtrrpt,'.ri,tr'rkl{[ rl'rrl[ihr.tr,ntrnrfo ^(,tr'(r I Nrodnnplt*rrhell( rr! rnd (lrunrt
<br />ndinr*aBl Strrc lrrsEkril{ ri' rii
<br />ih^c h*nriotu1l pn,p.ny nn 'n\F{K
<br />u{'rA^J
<br />Set Backs
<br />Forms/Sleel/Holdowns
<br />Erection Pads
<br />UFER Ground --
<br />SLAB Floor ''.tt
<br />Sublloor/VenVl nsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsu latio n/E ne rqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enoineer Final Beport
<br />Flood Zone Certif .
<br />FINAL 7-28'22"'/Je(,q)
<br />Certiticate ol Occupancy
<br />Notes, Remarks, Etc
<br />Brown Coat
<br />-l&Etnd*illnd
<br />ail *orl.n F,{.trsri'n itr*trE...i E!!i,t{ b, Salbn l700of rrE trlrtr co&,lor llr Frfolrw. of
<br />rlE mrt lm *hth rnn Frmir i! nri.d M, mrrn onqEdirn in$rm ori., nd Fl..y mtft. E:
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