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BUILDING- INSPECTOR RECORD
<br />SITE-WORK ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcrcbt nmnn undcr p.nnlty of Dcrjury llur I um cicnrpr liom rhc Co,tacroN Li.cn\. ti* lor rhc rbllowin8 rca$n {s..70115
<br />Busircs md ltofc$io! Co<lc): Any cily or (bunly whth rcquircs . ,,.t.ril ln .on(ruc|. Elrc.. ihPrcvc. d.n,lish ur Eroinry
<br />rdcrurc. trior ro irs issurmc. .l$ .cquncs rhe oppliclnr lor such pclorir t,6l. r signcd n cnrnr rhlt h.or sie is lic.nscd FUKUnir
<br />lo lhc pmvni.ns ot lhe Conracktr\ Lic.nscd L.w (ChnPtcr 9. ComnrcNins *irh s.crnn 7m0 ol Division I ot rhe Btrsiits r.d
<br />ProL{\bns Cod.) or rh hc or \h. i{ ex.mpl thc.clroara rh.h!si\lorlhc,lk!.dcxcmPlion Anyviololio.orSe.ri.n70r1.5byany
<br />{plici lor rtcrmir subjccts rhc rpolicsnr ro ! cilil pcn,lr, o{ nor nmr hm fivc hundrcddolhr (!5m)
<br />-1.
<br />rs owocr ofrh. ptuFny. (tr mycnrployes silh saScs as rhcn $t comFnsalion. willdo lhc wort und rhc dtuh n ml
<br />icndcd.ioflar.dforslc(Sa.7O{4.Blsine*andlt'fcsk'nrC.dc'Th.conrisclolsLiccn*t!*dernor,pllyloanosDcrot
<br />rhc poFny wh, tri[Ls or nnpbhs rhcen. dJd who dB eEh wo't hinsclfor kmlror ihmu8h his.r hcr own emPbyccs.
<br />pn)vi.lcd rhar ruch imrrokm.ls m mr inlcndci d olt!rcn for sle li howctr. rh. huiui.e or irrottnEnt is sld wirtin nnc )t.tr
<br />of.o illcri,n. rhc t)wncr BuiUd will Mvc rhc burd.n of F,vi$ rkf lr or shc dxl tror ttrild or imfmve rnc I$Fny for rhc rurFN ol
<br />4r. asowncrotrtrcnroPcny. amexclx\iv.lycotrtidnre wirh li.cnscd.o rrcnrF b cuneru.r rh. pmic.r (se 7014. Btrsimss
<br />and PR,tcssbnCdlc:ThcConka.roasLiccnsctiwdocsnolapflylo!nos d .r tnrPcny who hu ilds or imlrolcs rhct&'.
<br />rrd trho rotrri.r(ki \'.hJnric.rr *irh r(innrrrd\) liccnrrd f!
<br />;l'"s'dlf."
<br />IIETI.AXAIJI}N
<br />I hercby afi'n undcr pcmkyofldju.yom olrhc followirs dcclaratn'ns
<br />-lh!rcanlsillnuitrr,i'ruCenifi.arcolConsnlloSelilnsurclo!wo
<br />en conp.nurion,,\ tn,vidcdforiySsrion.l7lroorrh.
<br />tabor Codc, lor rhc prforrorcc oI rhc work for which rh. pcrnrn i{ isucd
<br />lnd*illnrinllinworkc^.ompcDs.ri in{riNc..\ r.quircihySccrnn]7mofrhctiborC])dc.i{trrhcp.donnrfrcof
<br />My vorkcB compcnelion inslrarcd cari.l and B,licy mnhcr ac:
<br />Co
<br />an(q o\qG,l'
<br />I c.nilirh.r ir rhc pcrfonnrncc ol rt. *ork f.r which rhi\ n rnrir i\ n{i.d.l \hrllDol.tr]Pki, rny P.'tun in.ny mtnncr
<br />$ $h lf,co'm suhjccr t) rh. sorkcr\ .onf.trsdlion hs\ oicolilnnri!, atrd xsrue rhrr ir I \hould hc.oE nfijcd ro rhc
<br />*orkcr\'c.nU.nsdn,nrmvisions.lSc.liotrlTL$ofihctjhtrCodc.l\hrlllnnhsirh..nrdywirhrhoslmvi\ion\
<br />llARNING: tlilurc ri {curc wortcr .unFtrlrrion mlcrtrEc i\ u l,slul. atrd shrll \uhicr an cnpk)rcr o citrriDrl ltDrlrics oni
<br />.ivil &B nn ro onc hundr.d rhou$iJ dollrs l$ll)o,(X)O)
<br />sc.rion.1076ollhc lfltu(1)d.. inrcrcn and xnormy {l&s
<br />DICI.ABAIIQN
<br />I hcrht attu nr undcr pcnohyolpclury rhar I ao liccnrn und.! Jm,visnr ofChfrcr 9(.omnrcncitrA wnh S..lir 7m0) ofDivi\ion l
<br />of lhc Busine$ und Pofe(i.nsCodc. rd myliccis is ir lull lhrccmlcffccr
<br />9j1 tL6
<br />olt," Ull"r' l{9-u-ti )
<br />CoNSI'RfICI'ION LENNIN(i A(;ENCY
<br />I hcrchyantur undcr licnrlrrolpciury rhrr rh.r i\ r conqdcri,n Lndi,rg agcrcy lhr rhc Pcrfitrmri.. orrra work for stich rhis Pcrni i\
<br />issuc (S.. l0g7.Civ. C )
<br />AITLICANI.ITECUNA&)!
<br />I IEDby alimn undcr pctrrltyofIrrjuryonc ofrh. lnlk,win! dc.l.rarions:
<br />Dc'mliri.. P.rnrns Ash.nos Notif,.ation fcdc.alRcgullti{nr (Iirle 40. Prn6)
<br />Rcqutcd htcr.f NoiifEiti.tr
<br />l.cnilyrhlt lhc ltdcrrlrcsuhrion\ rcgrdiiSrsh(no!c rv ldc mr rpdiclhlc brhn lior.r
<br />l.cnil.v rhrr I hrvc tuM rhnrffl
<br />ordi'r ic.\ntr srnrc tIVsrcldntt,
<br />rhcrlx,vc i',forn ri(m is.o'rc.i I rgcc ro..nrply*irhtrllC(yitrd C.trlny
<br />nrsrivcs oflhh Cny Dnd C{,unryr. cnrcr qrn rhc
<br />dx,vr tunrnrcd n()!cn! for
<br />IDDlir.trt or ASul Si8nrlu..:
<br />Set Backs
<br />Forms/Steel/Holdowns tlt,\\7 .,?Y
<br />Erection Pads d'/.J
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Roof Sheathing l0-il -r8 17c.2)l
<br />Shear Wall 8-25-t0 ,C A1 btq 9il hA1
<br />Framinq n-/c-A 2/-2.-tl ,
<br />lnsulation/Enerqy I lu tt t"t 7/.4-, t-
<br />Drywall ,/o/tt /tk r4nm.*7
<br />Ext./lnt. Lath ,h/r^{/tr &vt/tT+1U'\-
<br />Brown Coat )oZc'rL ,Q,a.u.x,,27
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />FINAL /23'/8 4( 21 ,/-,az e c.a/.a/
<br />Certificate ol Occu n 2
<br />Notes R arks, Etcsr '2t-
<br />-//-/a/r/
<br />DATE
<br />i's'\B
<br />,,,"' E- g- t,
<br />trnd.J! Addrs.:
<br />-
<br />LIZ(rS
<br />,,",. r'9-(8
<br />I
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