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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE COMMENTS OWNI]R IIUII,DFJR D!:I,CARA'IION
<br />I hcrchy affirm undcr pcnalry (,r Frjury rhar t m crc'np' rn'n rh. o)nLi.ro^- Liccnsc bs lor lhc nnbwiry rca{,n (Sc?0115
<br />ausiic* rnd PR,Lsion Gxlc) Ant Cny or Coutrty ehi.h rlr]utcs I JEnnil ro con(nrcr. Ilt.r. impn&, dcnn,lish or tulln ,ry
<br />iruclurc. pri ro irr nsuincc- ako rcquiBs lh.lpllicsnl hr {rch pcnnit lo fiijr \irncd {rrcftnr rh,r h.or shc ( li.cnscn Pusuanr
<br />h rhc ftuvhion\ of rh. Conta.iols Liccn*d tj* (Ch!|,cr 9. Co,nnro.in8 wnh Scclion 7(xX) ol Dilist'n .l orr[c Bu\nr\s and
<br />Itorassidr Codc ) or lh h.orshc iscxempr rhcrcfror unn lhetori\ tn rhc allcgcJ ercnfrn Anyvn,lootrofSstio?03r 56yany
<br />rpplicairturaFrnrir\ubrL{rsrh.fllicnnroicirilFnrlryofnormmrh,lvchundrcddollars(S5OO)
<br />I. .N osncr ol rhc ltrottrny. or nry cnDloyccs *ith woScs rs rlrcir s lc dnnpen\lri(,r. si]l do rh. work ,nl rlt sturuc h trol
<br />inrcndc orollcrcn 1or {,lc (Sc 704.1, Bu\inr\{ rnd P(,lc\si{nn C{rlc:'I hc Co racrtr s l-i.cn{ Ijw dcs nor alply ro rtr o*mrof
<br />rhc pD,f,ny !ti) huil& .r improvcs rh.E,n. ud who m\suchsorlhim\clforhc^clforrhtuuAhhhothlr.rncmpk)yccs.
<br />fmvidcd rhnr \uc[ i'qn,vcnrmsdc tror itrrc slorolhrcditsih llh rvcwr.llr bnikling or i'npn^tnr isn)k]wirhironc)ut
<br />.l.onlnldbn. rh. Owrcr BuiL]cr wilihr\r rh. hxrJ.n or pn,ving rhd tx orrl[ dkl ior huiU or i,l!0mtt lhc Impriy for rhc prrF){ ol
<br />-1.
<br />as oqrcr .l rhc pmpcny- om cxclusircly conrracr ins wirh liccned conrrrron n, con(tucr rhc poj.d (sN 7(}1,1. 3u.inc$
<br />rd PDlssi,. Codc: Thc Contdr.r's Li..nsc La* doca not aprly b !tr oq.cr nlpropciry who l,uilds or nnprovc\ rhcr.on.
<br />rnd who conrru.ts lnr such pmjNls wirh r Conrrack( s) lilrn{d pur!'rnr t' rhc Coitrctr\ t-icdtrk La* )
<br />I .n.x.mpr und.. Sc.rn
<br />uoaxESll:ouff:NsarloNDtrcllnaua!
<br />Iluchyrfln unddr pcMlly of nnjry .ne nfrhc rolnlwirA dLrhr.riotr(
<br />I hrvc rld willnrrnr.in ! Ccniicrlc oiConscnl roScll.lnsurclorworkcn compcnsaii{,n.as ptuvdcd fd byScclion3?mollhc
<br />Ltrllr C{xlc. for rhc n nar.Br.c olrhc work for wnich thc pry rn n nrucd
<br />_l hlvc nDd *illnuirhin workcn con,Fnsari.n in\urincc. rr r.qun d hySc.rii lTtX).lrh.LrhorCodc.lnrlhcpurlorm n.cof
<br />rlE sork,nr shi.h rhis li.nnir i\ i\\dL{ My qorkcF ..trrtci\rrn,n inntrd..c.riiicr iftl Nli.y nu mhcrurc:
<br />' <.lt/t 6a,, e
<br />Eotuj /3 f
<br />l.c(r[rhnr th.pcrrannnccol'lhc{orkturwhichl[nNnnii\i\{rd.l\h]llnorrtrpk,yn.yPchoninanymrtrrcr 'v) x\ ro hccom $l,iccr t, rh. trorkcA ranip.i$rnin hw\ ofCrlilarnir. dd reNc rhrr i, I \lniuld tEcoN \uh]c.r ro rlf,
<br />*orkcr!.on,p.n\nri,)npmvi\n,n\ofSccrioi.lTlX)ofrhctjhtrCodc.l$ll.fonhrvilhconrdywilhlhocpn,vni.ns
<br />WARNIN(;: F htrc lo so.urc workcm conrlf,nsri.tr..vcrn8c i( urhsiul. lnd \h!ll \ubJcd ![ c ill.y.r k,.nn1im] lEmhics dnd
<br />rnil fiD.\ up t, otr. hundr.d rhou\lid onEndion. dtuses s, tsvidcd lor r,E
<br />7
<br />I h.rbr,frtrm uMcr lrn,lryoip.rrrylnal I a'n lianei undcr !rcrniotr ofChaprcr 9 (@Dmmiig wirh s.dion 7uJ0) oltlivision 3
<br />ol lhc l,usircsrnd Polcssions
<br />a/o i..ns.Ntr,nh.r: , (770q I
<br /></t conrartr,L
<br />Ihcr.hytrllirnrundcrF-nihyofnr]!ryrhdiltcdi\r.onnocriDlcndin!rScNytulhcFrlbnnrNcoirhcwolkf{r*hi.hrhNtf,nnns
<br />r\nrd (Sc. :11)t)1. (-iv C )
<br />ASIUqANLP&CLAB TAN
<br />I tErhr,linn uod$ pcnElryofp.rjury onc orth. aollowing d.cla.rions:
<br />Ocmlirion Pcmirs Ashcsros Norifi.drion Fcdchl Rcgntriions (Tnb40, P.n6l
<br />-Reqltcd
<br />ldrcr oi Noif*arion
<br />I ccnfy thar rh. fcdcmlrcBuhtions rcFrdins as$rros rcmorllirs
<br />"or,pplic|hlc
<br />io rhn rm,c.l.
<br />-!cenityrharlhalcrcadrhlrappliorionalts,icrhrrh.abov.inrdrroroniscoded,4NloomplrwilhallCiryrndCounlyoniinrnccsrfd Sr rr !:t*\ Rldl"s n, tu'ldrA.otr{fl.r aM h.rcbyaurhorn rqrrcscrrariEs of l
<br />ntx)vc nErriurc tropcnyi(tri'rnccriiin
<br />,\ppli.ont or As€nl SisMture: X
<br />P"*ft"" nr."rp;nrt, I @a*?
<br />Set Backs
<br />Ereclion Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loorivenVlnsu lation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />FINAL <lLtll9 _-012, f s)
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc.
<br />ID/SIG.
<br />Forms/Sleel/Holdowns
<br />T-Bar
<br />I
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