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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS 1)WNER BUILDER DELCARA]ION <br />I h.rcby am n und.r Fn.ht of r.rjury thrt I m cxcn{ ri.n lh. Conr..ton Liccnsc u* lor lhc iolkJ*ins m*)n lsc.70ll5 <br />Bu\i.es r Pr.lc$ion Odc) Any Ciry or Counry *hi.h rcqutcs ! If,mir io conntucr, akcr. inl,rovc. dctrblish ,tr rcliir Jny <br />nrucrur.. pr birs i$orkc, al$ i.quiftsrlr applicMi for su.hpcnnir ro lllcr siBNd {drcmnr thal h.or shc is licciscd pu^utrir <br />t, ihc provhions ofrtE Coor.uclorr Licenscd lj* (Chaprcr 9. ComnEncir8 wirh sccrion 7(xn or Divisior 3 oi rhe Dusincss rod <br />Pr)fcsion\Coild)orrharhr orshd ilcrcnrtr rhci.fr.mand rhc ba\n f{r rhcall.B.dcrcmpli,'n AnyviohlionnfSccri,nT0.ll5byrn, <br />rpplicad lor 0l)c rnit suhlcck rhc analicrnl ro !ci!ilpcnolrlolnol nMdhln five hund!.d dollan ($500) <br />-1. <br />rs owncr orrhc pmlEdy. or nry crlll,lort{s wnh sascs,s rh.t slc con{Ens&tiotr. silldo thc *olk aJd rhc {turm n mr <br />inlcrncn or olttrc'l lor $lc (Sa.7044, Ausines and Aoiclsions Codc'rhe Conr.acttr \ l-i..nsc bw do.s nor aptly lo an owncrol <br />rhc pmli.ny who huilds or nnFovc. rhf,]mn. d wlb des su.h md( hinNclf or heNcli or rhnuAh his or hcr ow. cdplofcs, <br />povidcd rharsuch improEmnrs uc nor inrend.n orollcrcd rbr eh l[ hosevcr rh. buildint or inPmEm is eld $irhin onc )tr <br />of$mpLrkJn, rh. Osmr Buikid *illlnvc Eb{dcnof pbvirl8 rhd h.oishcdid mt li{ill or ni{ovc $c pDpcny aor llt pu{xts of <br />-1.!sowncrofrhcpm|Eny-amcxclusirclyconrrldirswirhliccnscdconrrdcin\bcon{rucrrh.tmr.cr(sc.7(l1-{.Bu <br />r$ <br />aM Pnnis\i.n Codcr Thc Contr.ror's Licctrsc LrB dms mr ipply b rtr owns oit'iopcny s'ho huilds or nnptr,vcs rh.r&n, <br />and who conrEcts lor uch rrojcls with ! Co.rr!do(s) Iiccn*d purunr b rhc Contrttr\ Lic.n\c tj*). <br />-l <br />lnei.mfl lndcr SaliorL-. B. & P.C. forlhis reso. <br />Drle: Orn.. <br />.UABKE&IIIjOMTDNIAII!}! <br />DEI;L$AIION <br />I hcrchy alfinnundcr plMlty ol psjury orc ollhc lollowin8 dellnlionsl <br />-l <br />hlvc ad will mirIlir . Ccn ifrarc of Con$nr b Scll lnsurc tur sorlc6' onpcnsrbn. as piovid.d fot hy Sal ion 3?00 of rh. <br />Llbor Codc. for thc pc.lormrrc of lhc wort lor wnich lhc pcmi is nsucd <br />Ihrv.a.dwillnDnrrairwork,c.om0.ns!iioninsurtrn.o.rsrcquircdbyScclion370{)oarhctlhorCode,rorthcp.raonn!trcof <br />thc qort fttr which fiis Frmil is iss(n. MyqorkBl compcnsrlion insuramc.aricr aDd polty numbcr ft: <br />-l <br />ccnilylhol h rhc p.rhrnmncc oirhe work lor whichrhh pennil is is$ed, Ishrllnor c rtl{ry,iyI'cson in rnynrn Nr <br />k,stb*omsobjccrk,rh.worr.rs.onrp.nrdiotrhwsorcrlilomr...d.BEcrhdifIsnouldhccomsut'idbih. <br />wDlkcs ..mpcnsarion lrovi\ions .f Scd io. lToo oi rh. tatrr Gxlc. I sha . tunheith .onDly * irh rh'e p virhnr <br />WARNING F0iln,. ro scurc wortcn ompclsllion c,vcmsc is utrlo*ful. !trd sh,ll rubJ.cr M cmplo)$ n) dinri.ol Fnollics lnd <br />civil ftrs uf io orc [utrdrcd lhousrtrd dolh^ ($l00.uD). ir addir r ugrs as providcd rhr rhc <br />sLrrior 1076 ofth. ljhtr Coic. inrcEslotrd ortormy s rcc <br />Dile: Applient <br />IhcrchyriirmundcrpcnllryolpcrjrryrhdLrli.di{dud.rptr,lisi,,rorChn|,d9lconnxncin8wnhScclinrTlxro)orDivi\n,n.l <br />oi lhe Busincssand Pronssions Codc, ud my liccnsc is in iulllorcc deficcr <br />Liccnsc Class:-Lrcnsc <br />a) <br />calSIBUCUaNIElDIxlirlliENCI <br />I hcrct y.flirn undcr pcnrltyolFrlulyrhal lhct il a mnslru.tion lcndins ascn.y ror rh. F.rfornBR. oflhc pork fo. which rhis [troi n <br />nsu.d (Scc.3097, Civ C ). <br />APPI I(:ANT DI](It ARATI(}N <br />l lrnty afllm uidcr p. rlry ot !.rrury onc of r hc r.lbs ir8 dccldl dr\ <br />D.'nolirn,n Pcrmit\ sh.ios Norifi.rrnd F.d.nl Rcduhrn)ns (Tirlc r(). Pd6) <br />R.qutcd trrrci.f Nobn.dbn <br />-l..nilyrl <br />rlhc lidcrrl r.Bularions rsrrlin!a\h.{.\rrn vrlrrd mr xfdi.rhlc h rl$ |no]c.r <br />l.cdiryrh& I hr!. rcad rhisapplicrriondrl {arcrhm rhu Dvc inhnNlnm i\ cotrsr I !crcro.o ply wirh rllCiryrnd ('ounry <br />ordim .cs and srdrc tjw\ rcldiryro bnildi iccs ofrhn Cny.nd Coutrly ro cnrs upo.lhc <br />rhrr rnrurcd F)Jr.nr_ ntr i'Npccrii) <br />,\ppliunt or ,\Scnr Sisntrlure <br />O ^J\ I,o*Uo" rr.",Onnr,l@ArU O-Sea /A <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />Subf loor/VenVlnsulation /a\ <br />Rool Sheathinq q,-2b-lY villw)=/\-t1 /+xttrCn€A <br />Shear Wall lt4z(N <br />Frami ng <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[/]aso n (y <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />E ngineer Final Report <br />Flood Zone Certif . <br />_i].i\\ <br />FINAL /o-z-/9,)*t>lz r <br />Certificate ol Occupancy <br />Notes, Remarks, Etc'27': /r1 0^/ !/ <br />SLAB Floor <br />.-'-"..4 <br />l{'Ji.'. 4d'1,c.. <br />I <br />T------ <br />I <br />i-