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<br />BUILDING- INSPECTOB RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS 0WNER BUILDER DDt,CARATIoN
<br />Ihcrbyaflirmunds E-nalry ol rr.rjLry Ihd I excmpr lio ihc Coih.rors' Liccnsc Ir,* tur rhc following r. v lS(70ll:5
<br />Bulncss .xl Prclcsioi C(rlc) Any Cir! .r Counry whkh icqut r I P.nnir r, .onnnrcl. allct. imtmlc dc'n,ish 'tr rcnJn 'v
<br />{rucrtrrc. rritrb ih
<br />^\urmc.
<br />rl\orcqrirc\ rhc lppli. r lor {chltnnirt) filc I siSncd srdrnrcnr thd h:or slt i\ li.c scrl pururnr
<br />lo lhc povi\i.n{ of rhc cotrrr3.ror'r Liccn\cd l-rw (ChrPrcr 9 c:dnmcncing aih sccrn)n 7(xxr ol Divtri'n I otr}6 Bs\inc's 'ryj
<br />apfli.rtrr fttr r p.m,ir \ubjc.rsthc aftlicrnr ro rcivilPcnrXrofnor ih,clhrtr iik hu drcJ dollar\ (l5O(,
<br />t
<br />I. rs own*olrh.rropeny,or rycnDlortcs*ilhwa8c\a\rhcirq,lcconlrnsrrir)n siudorlruork drh.nrururcirnol
<br />i cfrlLi orolltrcd lor slt (s.r.701,1. Busimrs rid Pnnts\tns (frle:'l hc Cotrti(roi! Li.cNc lr* docs nor arPlr ro rn osNr ol
<br />rhcpn,Fi! who builds or i,{n)v.! ihrsD. irrl qho dcs suchslnihnnscllothcr\cliorrhrctghhis or h., own cn{k)vcc\.
<br />Dr)vidcdrh, \u.h i'np(roEnrs c nor inrcndcd or ofi6rcd fttrelc lt ho*cv.'. rh! l,!ildi'!! ornnnrcvcrnr i\{ld *irhinfm rtr
<br />ol.omtlcrion. ttt Owncr auikLr willhr\c rhc budcn ol pnNi'rg rhrr hc.r shc dil mr tuild or imnrort rhc pmrtrrv ltrrh. Nqh{ ol
<br />I
<br />I-r-i' ,,",", .r rn" n-rn y n r\ hF' lcly (nnkr.t
<br />'nri
<br />qirh hcnscd conrrtrctn\ b .on{ru.1 rh. Pn+d l Scc. ?04r. Br'i[ *
<br />4nd l\rc$,nCu'I Thr(i,nrrJcr{'\l'rLn\rL.'*,1',c\norrt'''lyromotrnurolFrPcnysiobuildsortnPnrlc(llxY'otr
<br />Jnd who conrEcr\lrru.h nroiccrs $irhrConkrcbn\) lircn$d Prsur brh.c. tr.lois l.iccn\c ti*)
<br />,^'r"::::;f)7lale lxrt ltjlrlof
<br />I h.icbyrfi rrfr undc! pcn,lryof Frjurtotrcorlhc tbllo*insdeclffirio s:
<br />-lhrv..idwillnEinloitraCcnilicrrcofConrnrloSclilnsurctnrsortcnomlcnsdn.asrovidcdrorbvSNlion:1700orrhcLlbor Codc. fdr rhc p.raormtrcc of ltc wo.* tu *hi.h lhc psmn n nsrcd
<br />-l ha!. trnd villnrinrrir worker' cory.nsarion iNuraocc- as rcqurcd bySGlion lT0,o.lrbc lj6or C.d. r rrhc rriom'cc ol
<br />rnc work for whi.hrhis pcrn r is ksuL{. Myw.rkas comFnsarion in\ur,tra oricr s,xl F,licy numhcr m:
<br />cdicr:-
<br />lbli.! Nr rhr
<br />/.,(r^,,-,n *u,-,,! ,tr ri bcu,nr.uh[!r rorhc
<br />rn c olric *ork tur whi.h rhi\ lfirnir i\ is\u.d. I nrll iol cn,Plot rdy lxts.tr ir anv nunncr
<br />work.h .oNpcns.rion l0ws otCrlifon,ir. d i!rcc Ihsr if I should tit.mc sthi.! b thc
<br />workc^ .o lp{.sntiulr'ovisi{,n\.fSccliotr3?lX)oIrh.l]hnCodc.ldrdll.bnhqirh.o rdv s irh rho{ povi\ ion\
<br />W RNIN(;: l]ailurc b ccurc rorkc^ conrlutrs rnn .ov.rr8c i\ unln\fui. itrd shrll suh].cr rn cNd.vcr b di' iltrl P_m[i's rnd
<br />!r otrc h!tr,lr.d thotr\ nd Llolhr\ lSll[)(xN)). rn xd,lrit]d ro rlt..n ol 1.I|{trrir.f. tlxnHlcr r\ fror]d!11 nn r[c
<br />Sc.rnn,:1076ofrhc tntDr Onlc, 'nr.rci itul inomy s lccs
<br />1{sl )o 18 nra,..,, )A
<br />!.IMA8!M
<br />I hcrchy rltnrrndcr p.ndlryolp.riury rhnr I a liccnul undcr pn,vnnnr ofch3lrcr 9 l.on rm inS silh Sccr idt 7ft0) af Divisn'n l
<br />.I rhc ansin.srand Phrc$6nrCodc. lrrl 'nr lhcns $ hlirlll'o!end.flcct
<br />-l,ic.n\c
<br />Nu *r
<br />coNsTRI lc,l.I()N LNDTNG ,{(;FNCY
<br />I hcahy.rlir undcrF'klryolpcduryrharrhcrcis.on(fl.liont insrsctr.yltrrhclcrtonudc.olrhcqorlrotrhiLhrhisrctnrilis
<br />i\sucJ (S...:1097.Civ. C )
<br />lxnd.i s AJdrc$:
<br />AIIIJISNLDEIIA&IIIAN
<br />I horhyrlnnrundcr nctrrlry orrrjury otrc ollhc nnh*i'rr dcclnratiors:
<br />Dcmolirn'tr Pc nirs Ash({o\ Norill.d'o. trdcrll RcBUhiiu,\I rirk'() 1'rrr6)
<br />R.itu [,11.1r.' rl Nor'li.ri.f
<br />-l.dlifyrhd
<br />rhc lcdcrllRgxhrn,ns rc8 nirg !sh.no\ rcnblal drc .o! rpPlicrhlc t, rln( fnu-.r
<br />fuk,,u.,',,'", ",..u ",'..'nr'
<br />tr, nn tr',1rirl' n!r\ r rl S'rrr I-rr\ rchrnF r, hu'Uiri!.
<br />rtxrc irloflNri,rn i\ c.nccr l rsre l. Rnnply wirn rll Cirl a l ( otrnv
<br />iil hcrcbyatrrhorizc 'cF.\cnrdlncs oflhn Ciy and Counlyt, cnrcr nlbn rtE
<br />rt$rc nE.rioncd !'opcny itr irr\tEcr ior nrrlr{\
<br />apDlicant orAs.nlsisnrture X
<br />Pemircennnr(Drrnr)i Y GA /^l t+eaL(hkl1
<br />-t f+/zt*
<br />Set Backs o,hrltu nrub/tu KZ--
<br />Forms/Steel/Holdowns 'b/lhlr*-A-na-/a--
<br />Erection Pads
<br />UFER Ground s/u/,lP 6rt,t ettt-ldi--
<br />SLAB Floor
<br />Roof Sheathino 4 2-t2-/f J&.e46 @
<br />Shear Wall /I r
<br />Framinq I v
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Fleport
<br />Flood Zone Certif
<br />FINAL ll-7-r?.VD
<br />Certiticate ol Occupancv
<br />Notes, Remarks, Etc.
<br />t-t-ata ot)
<br />e I
<br />u)J
<br />It-?-tq
<br />-)
<br />Subf loor/Vent/lnsulation
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