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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER AUILDER DIiLCARATION
<br />I lNrcby 0,nm under rcn0lly ol pcrjlry rhai I n crcnrfl Im r rhc C.nka.r i l-ilrnrc L.w tot rhc toll.Rin8 rc.$n lss.7(rll.5
<br />Bu\inc$ .fr1 Proacssn'n cldci Any Ciry or C.trmy shi.h rL\tunci a lEnnir ro ondrucr. ,xcr, rriovc. dcnrchh o. rcpan 3try
<br />dtucru'.. trir ro ir\ irsuamc. dho rcquircs rheaptli.anr lor suchFnnir ro filc! \isncd $ar.rit rh lEor she n li.cns.d Nrsur'ri
<br />rorhcprovisionsolrhcConrrador\l,iccn\cdLus(Chaprcr9.ConnnckirS*ilhScctintrTOtx)ofDivist:rolrh.Busi.c$.nd
<br />Pnfcsn,ns Cod.) or rhar lt or sh. i\.rcnrpt r,Erclr mlndrhr h.sk li,rlhc rllcscd crcn,fli,nr Any vi.l.tiotrofS.trion70.ll5 hy any
<br />n',pli..nrlo,nNnn,lsubj&lsrhe{p!licatrrx,acivilpcnalryofnorN,c$ fivclrtrtrdrcddoll.nl$5$)
<br />L a\ osmr of rhc pn't*ny, or my cmplor.c\ \ irh {upcr 0s rhcn eh onlP.nsd n'n, wdl do rh. *ork ! lhcsltulurct i.r
<br />iNc.lddl or oilcrcd l'or elc ( Sc. 7044- Busine$ and Pmhsn,ns Codc: Th. c.ntdor's Li.cr$ tns doc! n r atfly ro ,n osB or
<br />rhclln)Fr, sho huildr or inrr)vc. rhcK)n. sxl whu dds ssh wor* himscli or hcnclf or rh rEhhiso.hc.owncnDbrccs.
<br />povidcd rnrr slch nnprorcnrnrr c r, i' .n]!al or ofi.m{, ior srL ,l ho$cvci. rhc luildir! or i pnrEflEnr h sold si(hiLr ,,tu ttr
<br />ol..trIildiotr, rlt Owmr Buildcr willhlvc rhc hudcn olpoving lhd h.orrhc dit tur huild oi hryrov. rh. nnpcny lor tl'i PrrPoi of
<br />_-l. r\o*mr olrhc [olrcny. r cr.h\ikly..nkNrins \ irh li..n\cd oitr.k$ n) .onnrud rh. |nid.r ( S.. ]l+1. lh{nc\\
<br />rd ti()fs\i)n Codc: l hc Cont(b-s Li.ctr\( IrLr do.r nor.pDly ro rtr otrn.r off'.t.'ry$h. huilds.r irntnvc\ rhcr.on,
<br />ifd \!ho..trnd\lhl!'c1,nmjc.r\$irhr(in.rrk(\)li.c\cd|{rarrt)rh.C.rtricroi\l.iccn\ct:*r
<br />I u cxcnrpr undqSalion-. B. & Pc itrrhi{rcrson
<br />IAlt$illr9llfl;Is llo!Ilfll,r!.!![I0!
<br />I hcrehy rlltrr utrdcr trnrlryolncrj',ry.m olrhc talk'sing Jcclrxr ons
<br />llrvcd trill r rihcciatralcoi(nnrcnln,Scllltrurcfttr$ukc^'.onrNnerion.0stm\tlcdforhyse.rn,n:r7(DoIrh.
<br />ljtxtrCodc. nr r hc lcrformN. of rhc Eork li, ahich rhc pcflnil is nsurd
<br />Inrv.r *lllnmi oin sork.N co'n|ttrs i{nr i'Nurrn.c, as rclrtcd hyS.di.n l7(xrotrtc l.rhorO)dc. fitr rh. l[rfornrnmcol
<br />i(nr i'rntrr ..(rrrnl ml tniv fuf$rr rr.
<br />5
<br />civil finrs uI h oic hundrc lhou{nd dollir (SllX).lII)
<br />\c n'n \)76. rhc lrh, Cudc. n crc! rnd buorm\ s fe.
<br />r i', rddirion ro rhc co{ of cor
<br />DECI.A8AIIO!
<br />I tercty !m.nundcr pcnxlryorFrjurt rhir I.n lian{d trndcr tmvision ol ChrPr.r 9 (ronrMcins wnh Scdion 7ux)) of(rili\ion.1
<br />ol rhc Busircs ind Pmfc\\iorrs Codc. and ny lic.nsc is ii hrllfokr art clfccl.
<br />a2
<br />^ IJo'l OOcr-rz1o1
<br />,-111\ I'l /u ru
<br />llNlIBrfCIlOnLEIDlNljrIC[NlI
<br />hsucd (SG. 1097, Ci!. C.)
<br />L.nd.r's Norrc:
<br />-
<br />I.rdcf\ Addrcs\:
<br />-
<br />AIELICANII)IS.AIAIION
<br />I tf,nhv iflirnnktcr |En.[y oltErjlry onc olrhc nnk]*i',8 d(l[.ri,nN
<br />Ilr.'frnirnD P.nnIr A$.sor Norilicarion ljcdcrrl kcEultrrions (Tirlc 40. Pan6r
<br />Rcquncd Lcrr.rot Norilicarion
<br />-l
<br />ccniiyrhlrthe fcdcml Esuldions ngtrdrg arb. osrcn)v0luc noleplicat'lc t,rhis pioj{r.
<br />)al.cn1ly rh.r I larvc rc.d rhisapflicrriono srare rhar rhc akM innmd idr is..rcd lrsreroconTlyqirhtrllciryrndCounry
<br />.'dinrn.c\ rn(lsi rr Lls! rc|dfl3 k, huildilrS olrht Cir, and c.xtrry ro.nlcr ulxu lhc
<br />ihvc tr.trrionc F)pcn,n inrp..riotr
<br />Applicrnr or Ascnr Si!n{turra-l'o-j,a"Y 1,7 20'18
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Rool Sheathino
<br />Shear Wall
<br />Framing 52:7//8 >.\a uet+*
<br />lnsu lation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lvlasonry
<br />Pool Fence
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL bflTlt 5\*
<br />Certilicate ol Occupancy
<br />Notes, Remarks, Etc
<br />T-Bar
<br />n,,,.,^.*. SALg!443x?
<br />lccnifyrhrr nrrtu p.rnrnunc.olthc *.rk lr rhichrhis p.flnir i\ h\ucd.l drll nor cn,do!nnl tf,$of ir anyn'rnncr
<br />$ $ nr hc.oN suhlccl lo lne workcr' coarpcnsrrion lass of Crlinmir. rid Urcc rh{r il'I slFu ld f"ro f, .uhFtr k, rh.
<br />\ orkcn' comFnsar ion novi\ionr of Sccr i,)n .l?fil of rhc l itxtr Gx!c, l shrll. lnrrhwirh. mplyrvilhrho{fovni.tr\
<br />WARNIN(; Ii iluic lo rrurc workcis'c.nrpcnsrlnnr covcrngc i\ utrh*lil. dtrd shdll (ubltcr rrr cnrtl,,yc. l().Tilnihl |t dhf,{
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