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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER At)ILDER DEI,CARATION
<br />I hcrcl,y rrfinn undcr pcixliy ol lcrjrrt rhsr I M crcnTr lron rhc Cont&th t-iccn{ ItrN for rhc follo*in8 rcr$n (Scc.70:11.5
<br />Bucir.ss .nd Prolis\k,n C,xlc) ny Cry or Counry whi.h rcqutcs r tldmir lo cotr(n'cl. ahcr. improvc. dcmolnn or rcprn !n,
<br />iru.tuc. lriorro irs h$n.c.ilsorcquncsrhcrpplicaDlrorsrhlf,rrrirrofilcrsirncdsrarcmnrrhlrhcor\hcisliccns.drursurnr?
<br />i, rhc pr.vnions ot rhc Contr.roa\ l-i..nscd t-rw ichalrcr 9. Cofrtrrci.ing qth S..ri 70OO oi Divkio. I olthc Busincs und
<br />PoL\sionsCodc) orrhrr h..rsl[ iscrcmpl rh.rclio and Ih. h*h t)rlhc dlce.d crcnrlrion AnylnnrtiotrolScdbnTl].ll5hyrny
<br />afl'licunl r'orapcirnii suhjcrsthc aDplicnnl ro a.ivilr).tr.llyoltrol.r..crhan fivc hn.drcd dollaF(S5(D)
<br />l. rs nwftr.rrhc pi(,lxny, o. my.mnloyNs wirh s aecs as rhcn s,h conrrnsdion. sillno lhc work and rlt slturB i nor
<br />inlcn+d ororicicd r'or solc (Sa.704,4. Businc$ lnd h'oic$iotr\ Cod. lhcConrrucroisl-ic.trscllvdo.siorRrrplyr. no*nrr.r
<br />rh. nsf,cdy who boikl\ or nr$rcvcs rhrdnl. rnl sho docr su.h *o* hinlsclfor hcrslror lhnn'Sl his or ncr.wtr carpl,)ycc',
<br />pioenhJ rhrr such nnpi('krknh ntu mr i'n.ndcd or ollcrJ lbr $!c ll k'scwi ihr hiklnrg or nn0b(mnt k htl sirhir , 'nc rJr
<br />of coq)L otr- ll* Os trq Buih.r f,ill Mrc lhc honlcn of pmunB rhr h. or shc did nor huild or iDl,rorc lhc lmpciy r(, r!. Ntn\d dr
<br />-l
<br />am cxcmpl utrdcr Secrnr-. B & P.C. n, rht rclson
<br />DHle ()nner
<br />Il!trtr!:trr!]ut[ltar]oN
<br />DE!:LrLBlIlllN
<br />I h.rchv xllirnruf(1.' n!nrlr!of Nrjur!.nc.l rh. la l,Ni're,l.clx' oD\
<br />lhrvc od willnuinrrintr Ccnilrrr.ofCo \cnrt,Scl n\u,cturaorkc^-..nrcn\nrnn.r( [ovidcdlnrhySc(lion:17({roirhr
<br />Itrtx, (ixlc. ior rhc rcrl.flmnce oflhc s,ork f{r n hich rhc |Ennir i\ i\su.d
<br />I hdv. rnd willnrinbin qorkfts coinlcnsrrion insunN..8 rcquhdhyScdiotrl7(X)ollhct hor(onc.li,rrh. t rf.rnr'nc.ot
<br />rhc work lorwhrh rhh Frnrir is is$cd. I{y wolkcn- con\Tn$r io. irqmnce caricr anl policyn!mhcra
<br />I.cdifyIhrri.rhc tlcrfoflnrncc olrhc work ror *|th rhis,knnit is i$ucd. I null tr.r cmnloy inypcAoi in rn, rtrrcr
<br />vrtr\ri'6cc.msuhnl-rn'rhcsorkcnconlpcnsirionla*rolCnlilarnir-ri reRrharil Ishookl tENm rrh]cn rorht
<br />*ork.F comp.nsrri{,r pn,lisions ot Smrinr .lT0O ol rh. l rtxtr (inlc.l \hnll. fonh(irh.onrdy wirh rhoc pr.vi(bn\
<br />WALNlNcr F.ilurc h {curc workcr onlnctrsdiotr corrirc tr tr.hstu]. rnd shtrll suhjccr !n cdpk,tcr n, $i'nilJ Pc rlri$ lml
<br />civil fir\ urr to ntrc lrndrd lhonsand dollfs {Sloo,urr. it irr(riri,r h
<br />'hc c.{ orcotlPcnsnrion. danrlc\ rs trvidcd r.r rhc
<br />S.cliotr 1076ollhc trhtr (odc. inrcrc{ r rrtrtrcy \ Lcs
<br />,,,,",MAY 17 2[18
<br />I hcrby "rfird undcr Forhyorp.rjury rh.r I m lionsn u.d.r ttulnnr ofChrptcr 9 (com,rch--in8 wilh Secrion 7uI) orDivhion l
<br />ol rhc Busincssand PmfessionsCodc. und n,y liccnsc h in fulllora tnlcfffti
<br />S dr161
<br />!4AY 17 2[l]8."",*",". fal.rr= '-
<br />CqNEIAICUQ&LIIDINI-&GIN!.I
<br />I hcrcbt nmnn u cr|xn,llyollcrjuryrhrlrh.rchIco.(trrcrbnlcndirs0sencyiorlhcpcrtormatcotrh.worknnrhi.hthnlrnnilis
<br />is\ord (Scc :1m7. Civ C I
<br />a.ttllclNfDlct t3AIl!.tN
<br />I ltrcbyain unlcr |xnnlly ofncUury om ollhc folloNins dc.,irdlir)ns
<br />D.m,lirioi Pcrn s Arh.st.s Nolificrrion Ftlcml RcBulariotrs (Tilc40. PM6)
<br />Rcquncd hnd of N.ritKarhn
<br />-l.cnifylhrlrhc
<br />ltdcrrlre8uhiion\ rc[rrdiDg lshc{os rer)vrl r.c nor ]Itlicrhtu t) rhi{fnlc.nr
<br />*#[n;llr,rl:l i,n,rn,l(rrr rh rrho rlxrr i',l,trfrxrrnr r.oifc.r I
<br />$ovc rrcfliotrcd fnpcny fq i
<br />Appli.. orAs€nlSiaslrm
<br />P€mrile n.n. ( prinl):-Qer4:'5:
<br />r!r..t,.onr t rir[ ]ll(iryrtrJ (i)unly
<br />trr\ ffrlrs Cir, rDn (in,nr) k, otrrrr tx,trrlf,
<br />N;t A. nl
<br />I'dlar
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/Vent/l nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing q/?:1 /(s ) n:;at c,n+*t
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It/ason ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Depuly Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL ?/2//6 a\\rx
<br />Certiticate ol Occu pancy
<br />Notes Remarks, Etc
<br />l. N owre.ofihc lropcny. xmcrcuncly conrrading sih liccnscd corrrlcror{ h con{nd rhc Inrrecr lSr..701-]. Busresi
<br />nd lh)f.ssbn C.dc Thr Conrn kr's Lrcn\. LaR docs nor amlr tu m or ncr or prolcn y who bnilds or inrprokr rhcr.on.
<br />rnd who onlmcr s ntr such projcch wirh a Conrrrclons) liccnscd pnrruanrrorhcConnmkn r l-ic.nsc l-aw)
<br />!,.\. \-u
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