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BUILDING- INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS oWNER AUILDER DELCARA'tION <br />I hc'chy dfin r und.r Nn.lry (Jf lcrjr} rh.r I im cxc,npr liorn rhc Conrrrtrn Liccnr Lrq ntr th. fdk,wir8 r.ahn lscc?0.115 <br />Btrrinc$ and Profcssion Codc): Any Cily or Orlniy whi.h r.qutc\ r Pcnnir lo cotr{ruc1. rllcr. imPmvc. dcNnnh or rc|ln rtry <br />strucrur.. prior ro ns istrxncc. rko rcquirc\ rh. rrpli.anr for \x.h Fnnir Io lika siStrcrj sllrrnrtrr ihai h.or shc i\ liccmcd N6 unr <br />b rhc mrvi\i(trs or rht Contrr.n" s t-i.cn{d ljw lchrprcr 9. Commncing wirh sr.ri.n 7(xx) oi Divhion I oi lhe Btr\incs rnd <br />ProicssionsCodc)or lhnr hcor\hc iscrcDpr rhc.clionrrndrhc br$ tur th. illc3cd crcnr!lion. AnyviohrionofSc.ri,)n70ll5byrny <br />appliun! r.r, F,trir \trhjc.hthc attlicrtrrlo a.ivilpcn.lryoinor nFrc rhrn ri!. hundrt.t d.lldrs (S500) <br />-1. <br />as osn.r ot rhc In,Fny, .r my cnDbrcs wirh *.8c1 is rhctr solc conrFnsuli,,.. wi!! do lh. "o* md il'c nrudurc n mr <br />inrckkrl orolftr.dr.reh(5(.7(11,1-BusincssandPrefcrsion(CnlcThr(nntd.ror'\LiccnscL.wdmrnoratrtlyromo*ncr.f <br />rhc nmpcny sho bui[\.r itr{troB rr*6n. s]rd *ho ddr sk'h w.* hnn\clfor hclsclfo! rhFlSh hn or h.r owncntloyccs. <br />providcrlrhrr such iDnmrcnrnrsurctr(n i cndcrl oroficrcd l'or \rk ll howcwr, rhc hnildinA ur innrcsrmnl issld wirhinonc )rr <br />or(,ndcrirn. rrr ow.cr auihcr Nillhavc llt bunlctr orlmvirS rhd hc or shc dil (n build oi irprovc rhc PmFny for ltc l,lrli){ or <br />l. rso*ncrol rhc !r)pcnr- trmcr.lusivrlycontrcring trirh li.ci{d.otrtr.h\ ro c.n(n'c(hc rmjccr lscc. 7l!{, BunNss <br />a Ln,fs.sn Codcr l hc Conrocroas l-ic.nsc t,i$ doc! nor aplly ro u o*ncr ofpfupdy trh() buildr nr improks rhcrcon. <br />rnd eho c.ntrls lor \uch pR'jcckwirhacl k,nn li.cn*J nursurnr r' rhc Cofrrlrin r l-icc sc Lra). <br />-l <br />!'ncicmpl utrdcr Srr <br />}to8trE853AU8[NS ru!I)lclrr&flQ! <br />I hcrchy rilirtrtudcr lrnrlryol t{rlury.!t ofdt n,lk,wi'!g dc.l.r dN <br />-l <br />h,vc mn *ill roinroin a Crniiiclr. orconsnr r. sclr ln{i€ rd eorkcn- .ompcnsrion. ss F)vid.n ror hy sorion l7(xr of rhc <br />hhor Codc. for lhc l'crformrmc oarh. sork for {hich rhc p€rnn i! i\rucd. <br />fl hrle and will maiirain work.R .omp.nsalion insurun.c. as Etuncd hy Sccr ion l?00 or rh. Ijhor Codc. for rhc ,)crfomrcc ol <br />11r \or[ nn s[i.hrh'\ lt'ntn ]\Itiysoikrrt..nr|\i\ ror i({]rxn.c.r'ricrrrl |xnq u tr d. <br />U 0 <br />I ccnifyrh r in thc pcdonnineolihc *ut li)r whichrhi\ p.nnir i\ ir$icd.l shallmr cmPl,iy rny PcrK,n ii rtry urftr <br />v, rrt,hcdnm suhjdcr k, rh. woikcn .otrrFns i(!r hes.f(-ilii.rnir. rnd4'c. rhrr il I \hould h.roN $biar brtE <br />uorlrr( .o rp. \xrnnr |n)visio.\.iSccrio.17(I)ofrhc Lrlnr Codc.l +ill. ftnrhsi!h.on\plynirhrhoEpDrisi,,n! <br />WARNINC: trilrr. n, ecur. work.r'.otrrt tr$ ioD..rcragc i\ utrl{\'iur- rnd \hrll \ubi.r n.nrtloycr u criminilraBlrics anJ <br />civil ljics trn ro oru hrndrcd rhou\aM dollars r$lll().fiX)). irr rdlilion to lhc cod o, comt icdiotr. dnnia8cs a\ nDvnlcJ lnr rhd <br />S.clion.l0T6ollhc l.rhnC(xlc. inrcrcn rtrJ in.nt! ! lcc\ <br />e\(t !^lt"t-" <br />I hcrcbyallirr uMcr lEnollyofpcdlry lnal I !h liens.n uhdcr ln,vision ofCh0Dt$ 9 (connNncins wiih Sc.ri.tr 70(D) ofDivniotr 3 <br />.r rhc Bxsinr*and Pmfcssiotr!Codc. ond my liccn{ n in tullli,'candcni.i <br />c trl 00 <br />,"," or/TrF.n?,o <br />is\ucdlSLt 1097.Ci! C.J <br />I.ndn (Nom _ <br />bndcis Addrcs: <br />-A-ttLLCANI"DEcl,rIBAfIaN <br />I teby fi.m udcr pcnalry ol pcrrrry unc of rh. li,llosin! dNlarariotrs: <br />Dcmniion Pcrnrils.Ashc(os Norificarion Fcdcral Rcgulat ids (Tirlc 40. Pln6r <br />-Rcquircd <br />t.llcrol N.nifi Gri,n <br />I.cnitilh0l lhc ltdcr.l rcsuhtn,ns rcsrdins r\hcno\ rc hv m. mr itlli.ahlc rorhisIn,Fct <br />{lccnifyrh lhatc,co.lihtrnprlicarionnllirr.rhrth.rh'\rnrronn ion hcorer la8rcch.omplywxh.llciryandCounry <br />oi{linrmcrr Sr c ltr's\rclrritrgh huiunr!(tr, Md hcrhyrulhorizc rcprcsctrrrrilNorrhnCiryn dCoonlyrocnrcruB,nri. <br />fixt mnri.n d psr.dy for insrc.rion <br />Afl,lidnr orA$nrsiInilure <br />LE <br />otlzl/b?.n <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />Subf loor/Vent/lnsulation <br />Rool Sheathinq <br />Framinq <br />lnsu lation/Energy <br />Drywall <br />Ext.i lnt. Lath <br />Brown Coat <br />lvlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certil. <br />FINAL 'vvz | ,z/Mj I <br />Certif icate ot Occu nc <br />Notes Remarks EtC <br />SLAB Floor <br />Shear Wall <br />lzo 2-,<> <br />I