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BUILDING. INSPECTOR RECORD <br />SITE.WORK ID/SIG.COMMENTS OWNElT BTJII,DF]R DEL(]A RA'[ION <br />I hcrcby Lrfinn undcr lftrdlry ol Fljury rntrr I ncrcml,l rn'n rhc c.ntr.chti l.iccn* l-a* lbr rhc rolnrqins rcnson rscc7l)ll5 <br />Ausircs lnd Pn'ics{ C{x]d): Atry ciry or Cou.ry whi.h requircr ! pcnir ro con{ru.r. allcr. inlPnvt. dcmrli\h or Np{tr rnv <br />{ crurc. priffto it\ n\uaNc. alh rcqutcs rh. ap icsnr tr \trch pcfl i t' lilc i si!trctl sldemni rh{ h.o! shc is liccntd l]Ursua'rr <br />ro rhe Drovhion\ ottt* ConrKlitr\ Liccnscd Lrw (ChrPt.r 9. Conlncncnrg wirh Sccrion 70(J0 of Divnbn :r ofrhc Susi.cs\ and <br />Pmfc$n,n\ Cod.)orrhirh... shc hcxcmpl rhc..liom rnd rhch\ir ntr rhcalhlcdcxcarPrion AnylnrhiioiolScdbn?O.ll5hyatry <br />rtpli.rnrrorrtxrhilruhjcchlhcrpplicarr...i!ll|t.lrtorfl.rnFrcrhanllEhundr.{lddUds($5Lro) <br />l. \.wi$ofrhcpn)pcny,orrrycnrpl,Dcc\wirhwxgc!r\rhcir{,lc.trfctr\nrnnr.trilllorhc$orknMrh.{mhrEi\nor <br />nrcRlcd oroflcrcd l'or srlc(Sa 7Ol4- Bu\inc\\ md Pnrfcssi(nr Codc f[e(onkrctr'\ t ircn{ l]q doc( nol llPply t, ri osnf oi <br />thclnrFny who hoild\ or imF)vcs rhctr\ . [I sh.doccs'chs)* htn\clfor hc^cllorrhrrghhir or hcr o*n c.tltDrct <br />t,rt'r cdrh such i'n|[Mnrnhrc nor i cndcJ orofiircd lnr s!. ll. hNcvcr.rhc huiliing orinPnrc'tum is *,kl $thin'ntr )ctr <br />of conlPkri,n ilr Owir Buildcr wlll hivc rhc nD cnolrovnErhrr hc.rsh. drl kt hnikloriDPmv. rhcprt)Fny for rh! t'uqw ol <br />-1.0(owncrolrhc <br />nm|tny. anr.rclu\ivclycunkrdnr! snh l,ccnul corirr.t'N h connrud rh flojccr lscc 7(}'1j- B!$trct( <br />Jd fh,rsshn Codc: Thc Cotrtacxtr s Licc.sc l.a* docs nor rptlJ- ro M owfcr of Proli.ny rho huikts or nnDroir\ rhcr.otr. <br />u !,h. conrla.k nn suc[ tbjc.r\ wirh r Corh'do( n liccnscd pununr n, rhc Coftnctrtr's Liccn{ ljw ) <br />l:'nrk'tr Ln'l.r\r.rur .B &PC |,trrln'.r{n' <br />Dllr ()wner <br />w(rRKE(S-COiIPFNSA I',ION <br />DESAAIIION <br />I hclcby affiru undcr Il.nnlry orFrjuryonc ol th\ rollowirB ncchrln,ns <br />-l <br />hlvcud *ill'ui' rinxCcnrllcrrcolCotrs.Drro Scli ltrsure lbr rork.^ (n\tnsirion.r pr.vidcdlorhrsccrbnlT(xrollhc <br />kbin Codc. tu lh. p.rli'rma .. ofrhc v.lk for which rhc,cnnil ir irsucd <br />rk trrrk n, rhi.hrhi!,rrnrir i\ i\{rd NIy qorko^ .o ,It \xr rr ' tr$[Jn!c\rr]c ntlt,li!) trutr,hrr Jrc <br />Taj,N firNJDSTAeauP€N S* <br />tt( 6 <br />-lccnilyrhi <br />nrrhc |frfortuncc ofrhc wurk Lr ghichrhi\ fcnnir i\ t\uo .IshrLltrol cnr oy ury E'or in nny iunNr <br />v, dt,trconr subj.rr r,rhc worlcF corrpctr\rrion hss.lCrlintrtria. d ll3tc. rhJl ifl should trcu'm srbl.at t,rlt <br />wo*crs conpctrsrrion povisi,,n\ ol sc.ii(r ]7m.f rhc lrhr codc.lshrll. lonhwirh.onrdy wirh r,nrs tovisi{)n\ <br />WARNL\(;: Frilurc r() r.urc sorlcF .onl^-i' nn, covcrilc i( unh*tu]. xtrd shrll su d. rd.ycr t).ri i',r1rmhic\ r <br />.ivil lnrcs xf nr oDc hundrcd lh.u$id ('-.J:i$#yuv' <br />DICIdEAIION <br />I hcrcby amrm undcr pcnalryofpcrjury rhd I am li.cnk'd undcr Irovi\ion olChrprn 9(connmming *iri S.cri,5tr ?00O) ofDilhion:] <br />ol rhc Busincssond Prntcssions C.d.. and myli.cns t h fu0 hrce ad crrd.r <br />*4i/ts LL <br />calsrxlcltgNlli luNc-dliEl.cr <br />Ih.rcby rftnrurxlcr l)cnrlry olF+ry rhrrIhcrc i\ a con{flcri k.dir8iScsyaorrhcPcrlnntD.coirlrworkf{nwhirh(hi$|lnniri\ <br />hslcd (Scc .1097, Ci!. C ). <br />AITUIANLDEILABAIION <br />Ilur$yrmnnun.lcrpcnrlr,orp.rjuryotrcol llt tullouirrEdccl uli,trl\ <br />Dcnk)lnn PcflnirsAsb$to\ Noriturri(,n Fcd.rul RcEUl.ri(rr( tl Ilc.l0. Pln6r <br />Rc!uircrl Lcrrcr ol Norifi .rri{nr <br />l.cnlfy rhdrrhc ladcfllrclDbri,)n\ rcxrdinsr\h(no\rc n*rlircforr!t,li:xhlci)rhnI()jrtr <br />//'()/ <a;> <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Sublloor/VenVl nsulation <br />Roof Sheathinq /o /n/tf,-a14q/ ) <br />Shear Wall <br />Framinq <br />lnsulation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Ivlasonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Repon <br />Enoineer Final Report <br />Flood Zone Certif <br />FINAL I b-a'/t/&1rvrl Hil-'- <br />Certilicate ol Occupancy / 'tt- <br />NoteF, Remarks, Etc <br />0 <br />DATE <br />L.ndcisAddrc$ <br />\ppliunl or,\ss'l siAh/itn <br />l'.rn,il( n nrlprinl): Y PttztJe WL.7P/LL) <br />Brown Coal