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BU!LDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS O\INDR DUILDER DELCARA'TION
<br />I fureby ,r,lrr oMcr frctr.lry (,r Fdury rhar I an ciempt lmm rhc Conlrrcros l-]ccn{ l-0{ for rhc lollowin-q rcasn (sc.?lr.rl5
<br />Brsincs and ltolision C.dc) An, Cir) or Counry shich requnc\ r Frmir r, condrucr. rltcr inrprovc. d.Rni\h or rcp.t int
<br />lru.rurc. tritrt, irs i$trun.c- 3ko rcquncs thc dprli.rnr I.r su.h Fnnn h filc !sigtrcil n .,mnr rhdr la orshc ir li.r \cJ fuAunr'.
<br />h rhc [ovnions oi rhc Cotrrrrckn s l-i.cnrd lrw (Chiprcr 9, ConnnrD.nrg wirh sccrnr 7(xx) or Divi\ion :] ot rlk Buitr.$ dn
<br />Ptuf.\\ion\CoJc)orrrulhcorshrtcxcr.prlhcrel'mmi rhc hr\r i6rhc rllce.dcrcoui(,n AnyviohrnrofSccriinr T0Sl.5 ht rtry
<br />0trtli.a ro..p.nnn subjL{r rh. applicanr r' rcivilpctrllry.fnor nFrdhln fivc hund.cd doll.m (S5mr.
<br />-l-
<br />as owrcr oi r he prcNn!, or my cmtloFcs wirh $aE.\ al rhcn R,h comrci\Lrnnr. will do rhc w.rk dd rhc nturm a tur
<br />idckkd or oorr.d ftn elc (Sr 70,$. Busincs ud Prot$nrN Codc rlr C.nr.ctof s Ld.sc h( docs nor aDnly ro rn o*ns ol
<br />rh.pmFny wh. huilds or impo!$ rh.rcn. *d *lkr dc\ {rh trt hnnsclforhr^clforrhn,rghhirorhcro*ncnlllk,yc.\.
<br />Druvidcdrhrrsuch nnpn)kmntecftni cidcd oroilcrcd fo. \!1. la horlvcr. rhc hlildir8 or iupovcmnr issoldNirhinooc rrr
<br />ol..nlpLrbn. rh. Osncr Btri crsilllrecrhcbordctrol'pmvilgrhdh.orsh.d nor tuilllor iryroE 0r pmFny for lh. purF)rol
<br />_1. isowncr.lrhctmncn!, amcx.lunvcly.onrncri'rc *irh liccnsd conrrrrn n' q)ndtuct rhc prcjdcr(sE 71x4, Bunncs
<br />.nd PDresi,n C{ c:'lhcConrrdlf s L,iccnsc l-trwdocs tror rftlyro 0trosncr olt'mpc twhobuild(orNprovcslhcrcon.lnd who conra.Flnr \u.h proj..rs sirh r conricr o,( , licc nscd punurnl lo rhc contuctor's l-icen* ti*)
<br />lxnrcx.nr|r utrdcr Sc.rior .B &|C turrh,\rcrnnr
<br />Dale Ownerl
<br />WORKERS' CT)MPT'NS TI(IN
<br />DICIAIAIIO!
<br />I hcrcbyiffiirnundsp.n!hyof ncrjuryorcoirhclollo*i,r!dccl ari(,hs:
<br />_,h[ro sillDrnin!Ccnifi.ntorCoisctrU.S.lrln\rrcior*orkcr'..n|rn\dnnr,r\providcdforbtS(Lon]Tmofrhc
<br />Irli, G)dc. turllrl[rfonnd ..ofrhc sork fu*hirh rhc pcrn,ir is h\uc,l
<br />lhrvd ri{l willmainlain worker' .ompen(i,nr iNurnncc. as rcqunL\l bySrdi.n lT0Oofrhc bbor Codc. lbr lhc EdornmNc oi
<br />lhc work for which rhis pcrmir is isw\l M y sorkcs conpcnsar ion insumncc clricr ond policy numbcr m:
<br />c""i. 5 .-ta-.
<br />lrg3'LL <lzq
<br />-l
<br />cediiyrhar inthc l]crlolrmnce otrhc sork nr shichrhnjf,nnir i\ i\\!.d.1nrllior.nfk,yriypc'{,. ia y irtrtrcr
<br />k) rt'b. nE ebjccr hrtu *ork.6' co m!.n sor ion hssolCrlllnari., itrd asNrh ill stuul(llicom subjc(rrorhc
<br />work.r{ compcnlllionln)lisions.ISccrion:17(x)oflhc titnr Codc.l{hrll. nnlh+ilh conrply *irh rhos pmvhion\
<br />W RNINC [,ailurc ro \ccuE r.rlc6 competrs.rn .ovcrrgc is trrhwful. a shdlsubjccr dr cnr oy.r ro flinriml pcnalrr\ nod
<br />!nil nnc, un n, onc hun!rc,l rhnu\anJ dnllir\ (!lrr).tlxl
<br />,,,., 511?l,r ^,X
<br />r)- in addition ro rhc cosr ofconDcnsnlion. dlmses N pn'vidcd rb! lhc
<br />LICENSED CONTRAC-TOR
<br />IIDCI.ABA.IIO!
<br />I icrcby dif,n undd Fnahy.rFrjury 'h,!
<br />I am liccned ridcr Dmvnbn olChaprcr 9(.ontuncins wirh sc.rion 7mo) ofDivki,'n.l
<br />oa rhc Businc$ ud ProL*iong Cod.. d my licens is in lull forc Md cILd
<br />azt
<br />n z?trr
<br />IQNSIBUCIIONIENDINGTTCINT.I
<br />I ltrcby ffinnonds p.nrlry orll.rjlry lhll rhcrc h a conslndhtr lcnditrs 08cncy a.r rhc p.riornEncc oflhc nolk f{tr *hich lhis pcrnril ir
<br />is\tcd (Ss .11)97. Civ. C.)
<br />a.trtlcaNtDlr;L taulrN
<br />I tEr.by lnifl und.r l.n.hy or p.rjury o e .r rhc n,lbsina dshrlr n,ns
<br />Dcn!,lirion Pclnih A\bcnos Norincirion [tdcml Rc8uhriotrs (Tirlc 40,l,nn6)
<br />Rrqoncd hncr ol Nolifi cltion
<br />-lccnilyrh{
<br />rlr,cdcr.lrcBuldiofs rc8dd'ng trshj{o\ rr x)ul rrc ior imhcrhlc b rh,\ pmjccr.
<br />Irr
<br />l.cirrrh,rltn,vcrcadrhi\lprlicarionand\urcthatrhcrhnri,rbm0rionhcordlasNroconDllNirhallCiry
<br />.rJi'rmc\ rn'l siJrc Ii\\ rcldinc l, buillingcnn{nicrinn. rd hcrcbyuurtxtrrzc rcrcscnralivcs olrhr Cil} !nd Counlyl
<br />utn\c nf,nrrncd nmncnyl,tr rn'n*lnrrrness -
<br />^rr^,*r., ^- Jt*",^*ry'
<br />-' %. tI"
<br />Femi,ename,Drin,':
<br />uArtbt.* H4g t
<br />Set Backs ,--\
<br />Forms/Steeli Holdowns lr't s)!'.e4.3(22)
<br />Erection Pads 7lt'a '\_i/'
<br />)
<br />SLAB Floor
<br />Roof Sheathinq
<br />Shear Wall
<br />\
<br />ln su latio n/E ne rgy 7/r//4 -<ffiZ,)
<br />D rywall (tv
<br />Ext./lnt. Lath I z/r//l .".M44
<br />Brown Coat C zlt z/rq 4tffiny.)
<br />Irllaqonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />l2--(tP l,C*v/ot
<br />Certificate of Occupancy/
<br />Not Remarks, Etc. (LL
<br />6L c
<br />c lla
<br />UFER Ground
<br />Subf loor/Vent/l nsulation
<br />Framinq
<br />FINAL
<br />txndc, \ Ad.r.\.: _
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