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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNT:N BUII,DER DI]I,CANATION
<br />I hcruhy lrfirm undcr Fnnlly ofltrrjury rh l N crcnrpr liorn lhc Conrlr.nr'l.i.ti{ Iaw ror rhc rollosillt rclen (Scc 70.115
<br />Arsirlcs rnd Profcs\n a(xlc) Any Cily or Counry shich rcquirc\ a p.nnir h .oNrru.i. nhcr. i ProN. dchoLlt .r ruPJn rny
<br />{n.rurc. prior h, it\ issuancc- aho rcquircs rhc lprlicxrr in \rch Fnnir ro hlci ngncd slalcnEnr rhlriror \hc il li.cn{d 4trr\uanr
<br />h rhc F,vi\i{,N of rhc Conrrcrofs Li.cnscd l-0q (Chaprcr 9. Commcrcing *irh Sc.rnnr 7mO .l Division .l ol rh. Bu\iics rid
<br />ProfcssionsCodc).rrhd( hcor sh. hcicmnr lhcrcfrorlnd rnc ha\i\ lo!rhc rllcg.dtrcnuiur Aflyviohrion.fS..rioiT0.ll5byrnt
<br />!t'!li.rnrfuIapcnnirsubjersrhe$plicanrt'r.ivilFnrhyoriorntrcrhM,ivchtr.drcddollarsl$5(x))
<br />I. is o*nnorlhc flo|Eny. or nry cnD]oyccs *ilh wtrgcs us rhcir \.k cotrrp..sarion. willdo ltE wori and rhc itrrur i\ trur
<br />inrcnd.n or oltcrcn for slt (SN ?041, Borin.$,nd I'r.rcsln,ns codr Thc Conr,aclois l-tcnr ljw dNr nor,pdy ro an owNr oi
<br />rh.pn,tEi, wh. htrildr or impmrcs rnc@n. and uho dms such *!rl hnn\clfdr hctrclfor thoulh hh or hcr oercmpbyccs.
<br />providcd rhar such impokft.r\ m nor inrcnnn .r ofcrcd for slc ll ho*$u, rt* building or irprorentnr i\ v,ld sirhin o'k )tr
<br />orconlndbn. tlE owner Buills *ill hrr lhc hrd.n ol nn,virr! rh,r tr or shc dil mt lditl or inqlovc rh. lm,Fny ior rhe IUTF,E ol
<br />l,^own.rofrh.pn,p.nt,.'ncr.lusirclycortdcriiauilhliccns.dconkrtrst).on(ru.rrhct)mjccrlS( 7(),l.l Bd\i,'r\r
<br />rM Fniissbn C.dcr'rhc Contact{ \ l-iccnse tr$ docs nor lPply ro rtr osncr o{nruPcny !h{) build\.r nnfrolcs rhcrcon.
<br />lnd *ho contrrc( r{n su.h pn,j..h withiCont cktr(,licc.scrl pur\u,nr t, rhc cotur&trt Licctr{ l3w)
<br />I smcxc'npr u.d.r S..ln)
<br />TOBtrEIII"I;AUIENSAIION
<br />!&gantrIlaN
<br />I hctuby alfi n urdfi r.nrhy of Fquly orc of rhc lollowing dclarurn,nr
<br />I huv. iJil uillrrui'nai.a ccniirorc oi Con*nr ro Sclf-lnsu.c tu eorkcd .uml.ns,tion.ns Fovided fo h, Sern,n l70o orrhc
<br />ltrbor C{ic, ror rhc l]crfomncc olhc $ork for *hich rhc pcrnril k issucd
<br />I h0vc rnd willmai.hin worterl conpcnsarion in\"ra.cc. as rcqoncd bys(riotr 37(t)ollhe lil,, Gldc, ror lhc,xrlomEtrcc of
<br />thc qor* r{ wnrhrhh llcrmr A hs.d MJ }f,r\cF Ti,nrru\d' n 'nrurumccJris Jr{l |'oli(ynumbfl m
<br />crr,: ./\t^-^ - ^/1 )/
<br />,.,,,,*'*IKAFv"{o-- L(rtrc
<br />- I trdily,hJr rhct.c'I' mtrn."nr't*[*u,*r',.t 'r'^1*cnll)loy.trypc6on ir uyd trnf
<br />!r st. b(nnrc rrbjcn b tlE workc^ conrp.nssri,'n hq\ otCalinmir. rtrd igNc Ihrr ilI shoukl hc..m \ubF.r lo rh.
<br />workctr conDcnsllion tovishDs ol Sccr ioi :l?(x) of rhc lltitr C.x].. I shrll. lon h$ilh onrPl, sirli rk*c pmvhn N
<br />WARNIN(; Frilorc ro rcurd qolkcr( coma.nelion covcn8c i\ unl,wtrl. md \hrll suhi.l u tmploycr t, dinri'itlF* ri.s rtrd
<br />.nil lnrr ut k) orc hu rcd rlDnsr dollrr\ ($l(x)-U)0)adJin,n b rhc .o$ oi comNnsrrion- lll n8c{,s frovtrlcJ lor rhc:::Zilry;:;
<br />t/Dl!lllil!.ltlll
<br />Ih.ohy3l1tnrunderocnlllyotperjurrrhlrInmliccna{nidcrptuvisn{ufChiucr9(conmnciuwirhs&(i)n70(x))ofl)ivision.l
<br />of ih. Busircssud Pm(cssioNCo c- d my li.cnsc is in full hrLr drl clL.r
<br />o/
<br />I:I)NET:BIqIONTENDrICA{iENCI
<br />I hcrcby rflnnrnd.r F.,lrt ol,,.rjury lhul thcrc h a con(rcrbn lcndin8 asen y ror rhc t rrormmc ofrhc work lor whih rhis F.nrir is
<br />irsucd (Scc.:109?. Civ C )
<br />Lnd.rs Nnflc:
<br />-
<br />d.TTUCA!1DDIITIBAII!}N
<br />I hcEty [mundf pcnrhy drt'clury onc ol thc idlowin8 dccl$rlbns,
<br />Dcmlirion Pcrmirs AslE{os Norinc,riotr Fcdcrol Rcguldiotrs (fillc.l0. P!'16)
<br />-Rcquncd
<br />t.tts ol NorifrariJn
<br />_1.{nilrrh3r rh. a.d.rd rc8ul io.s rcBadi.E $tf,sosrcnov.larc nolappliclhlc t, rhi{ pioj.{r
<br />I cmify thar I hNc aad thisapnlicd n {l{irc rhrrrhc rhn. i',lonn , rconccr l rArLtrocornplt*irhrllCity.nd Coumy
<br />ingc.ndtocri{nr. rrJ turchr urlxrizcrclr.scntulivc\ol'lIi\Ci!]rtrJCounryroctrreruI.rrlEoiliDatr.cr rtr(l Sfur.l-au\ rcl ingl(i
<br />rtx,rr nanriinul l[,]^-'nv nr if\t\_l
<br />,\plicnnl or ,\xml Sisn lufr *'r L:/ co r
<br />y''z/ts
<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 />Framinq t0-s-lr Y.\r,)6)l
<br />lnsulation/Enerqy '\/
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certif .
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<br />FINAL l0-71-lv x-vJl0
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc.
<br />7+q 4
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