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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS 0WNElr AUII-DF:R DCLCARATION
<br />I hcrcby rllirnr u dd |f,nrlry .i !.rjurt ihrt I !n ctnu ln n rtu Conrrt,^ l-ic.ns. l-tw lor rhc roln,sinS r
<br />Bu$ncs aM Prolc$ion Codc): AiyC y r Cotrnry Ehi.h rcquirc\ r n nnir lo cotr(ru.r. drcr. imProvc. dcnnrlhh o' tp n rny
<br />snrcrurc. lior ro irs hsuatu.. nl$ rcquircs rhc 4rI'licanr lor \uch lLrmn l. filc! \isncd {rr.'ftnl lhd htor \h. is li.ctr\cd Pusurtrr
<br />k, ihl p'ovisnr$ of rh. Co fucttr s Li..nscd Lrs (Chrnrcr 9. C.nrmcncint wirh Scctioi ?U)l) ol Dirtion:l otlh' Rhin'\( xnrl
<br />Prol'cs\iotrsc( c)orrhnrhcoilhciscxcm rhcreliorand th. hsi\ turrhc rllc3cd cxcnPrn,n AtryvDl.tionofSc.rinrT0:l)5bvonv
<br />opplic!trr ri-arnnir\ubjcclsrhc uprlicr r t, rciviltcn lryolnor nrrcrhrtr fivc hutrdrcddollan ($nn)
<br />l. us owncr ol lhc lr,If,nt. ui r! cnnl(De( *irh wagc\ r\ rlrir v,lc comFrlirnrn *ill ilo lhc w.rt nn(l ln. {nrnrc i br
<br />inr.nJcd orofltrcdforelc(S(.7o,1,1.llusinc$,ndI'mits\io(Codc:lh.Coitkkr'sLiccnscLawn.csn.r.Pllylorrosn.rof
<br />rhc|n)lf,ny s,n, huilds or nnprorcs rh.Ntr. RIwlhdft\\ucnworkhnn\cllnrhcr\cliorrhrn'shhir.rhcrownenfrov.!\.
<br />p'ornhl(htrrruchimpn*rr.r.tcmri.rcndcdorolIcnJlirq.llln,scvcr-tlEIn'ikli'rgornn0r.vcrrnris$ldsirhnoic)t
<br />olconrplcrion. rhc O*ncr Buitlcr q'll hrvc rlE hrdcn ofOoving rlxi h. or shc dkl tror huild or inDmrc rhr FJncdv f.r rlr luqrM of
<br />-l.
<br />rs owncr ol rhc ln,!dry. amcxch'\nrly.ontrctnssirh li.cnscdconrrxct,^k,..r(nrcl lhc nr+.rrS( 7044. B!rnc\\
<br />xl PtuL$irtr Codc Thc Conr!.nn r Li.cn$ L!r' iocs ,rdr onply h M owmr ol Dropcny who bu ildt or inrPrctcs rh.rc.r.
<br />and who cont..rsLr such nrcJcck wirh !Conhct,ns) Ii.cn\cd Pur{'a rolh.An rn tols l-iccn{ l:*)
<br />I rn.rc rt, trrrlcr S.di{nr .ll .\ l'( lnr r[r rtrn
<br />D.lc O*no:
<br />woRxria L(tNtm'Ns^TIoN
<br />DIII.AXAIIQN
<br />I hcruh,afir uidcr tr.nrllyolI]l juryonc orrhc tulk,qing dccl{riiionY
<br />-lhavca
<br />will'to,i ainrCcnificarcolCon\rnrbS.lfl'rsurclnrworkcrrconrljtnsdion.rs rrovidcdforhyScction:lToOolrhc
<br />tib{tr Gxlc. lor rh.,rrromr,f,. o, thc wo* lo! which ihc ptmir h is\ucd
<br />I hNc rnd willtr$inriin workcri cotrtfnslrn r insur{n.c, {\ 'cquncdhyScclior.lT({,oilhcL$orG)dc.lorrhcFil'nnxkcoris\Nd My workcr' .onrpcn\ ion nrtrrd .c.iflicr trfrlpoli.y in rh.r irc
<br />djiltz,-r,,".,n*1off92y' t''" t t -1 t'*
<br />l.c'nlyrh^r if rlr Nnni,r cr ofrhc w.ik n)r trlrrh rhirtf,r'
<br />v, r\ k, hc.om s,hjcd n) rh. tr.rk$s'.onrl{nsxri{,,lxw\ ol(rl'la
<br />$orkr'' coi,Nn\rrtr Dr,,!rsi,,n\ ot S(rnr l?rx).trhtLrlrr (.(
<br />rr \l.NINC l:'lu'.1,".n- \,rld\.1{nfr\,rnrt r{:,8 r
<br />,ir t i\nul, I sh!ll nol .mploy rny pcri.tr nr Bny nDnncr
<br />ario. rtrd agtu rh{ irI nrud hcmm nrbjcr '.tltlc. I shdl. fodhwn[coflply wiihrho{ P'tvi(ions
<br />unh$ful. !ft1 sh3ll suhiat .n cmplorr ro rimiml {tcMllics rni
<br />.ivil ljNs up t, otrc hx dr.d thousrnd doll!!\ (nl(n),lxnr. i"6+i;;::."Sc.liotr .1076.1rh. trhtr C*,.o?/o
<br />I hrfth!rlrn tr dcr trn v.l Jxriurlrhrr I xnr lrcNc(l ,,n)vi\ on.l Chrpl.. O(.onnncncn,g wnh Sc.ridr 7(xXrr of l) \r\i(rr I
<br />p' t-r'""r*l(
<br />*nr(lrS.. rorT ( i! ( r
<br />APPI ICANTDlr(II AIIATIoN
<br />I h.d,,am uidcr F.rlly ol!.riury onc orrhc r.lrosins d.c,o,alions
<br />DcB,liri,n Pcnnnr Ash.stos Norificalion Fcdcral Rcgulrri.ns (lirlc,llr. Pln6)
<br />_R.qut d hn$of Notificdion
<br />l.cnilylhrrrhc l.d.rJlrcgulrrionsrcgmll,g r\lr(os r. o\rlnrc trorrPnli.rblc ro ihi{ fhjccl
<br />i\..nt.r. I rgrce n'.omrly wnh rll Cilynnd (i,unry
<br />ruflc$nrdivc\ ol rhis Ciry and Counl, r].nicr utx)n rh.
<br />(
<br />q/@s
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsulation
<br />Rool Sheathinq 7,r,rY,,r'-/*1
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lt/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Ceftif
<br />FINAL 4 lThN\'to"nlte-l 'e->)
<br />Certificate ot Occu anc
<br />Notes, Remarks, Etc.
<br />I
<br />.r rlr llu\i',c$rtrd l\of.si,rl\ ( q1.. rrln,y hlr \cn rirlll,r..xftldlf.rr
<br />I 'J, ". A,U'...
<br />--
<br />rlrr I hrvc rc rhir rfnli.rrn)n Jxl nJrIhnr llr rlr,vr lnlnflnrii(r
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