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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BT]ILDER t'ELCARATION
<br />I hcrch, sii.n trnd.r pc.rhy of Frrury rhar I m crchpr rmnr rh. c()nhrctrn' Li.cnsc ti$ io lhe rblbwin8 rc,{ni (S& ?0ll 5
<br />Burnrss .lrj Pdassim Codc): A y Ciry or Coutrly *hi.h rqunc\ ! tcnil ro .on{dcr, rhcr. inr!rcvc. dcnlolhh .r rcFtr rny
<br />sddurc. Irirk, irr isurncc. rko rcquircs rhc rpllicrni for nrt Fii i! r) lih r si8ncd sllcNnt lhal h.or shc i\ liccn*d punuanr
<br />h rhc ptulisi.ns of rh. Conrmctols Li.cnscd L.r' (Cn.plcr q. (onrnEnci.S sirh Sccrion 7m0 of Divisn,n I of lhc 0usines\ rnd
<br />Pon$io trs c-od.) or r h.t lrorshc hexcDnl lhercfmn and lhchorh tor lhcrlhscdcxcnlprioi Ahy violarionofScciiotr?0:ll.5 byany '
<br />n,,plicaor lor a rcnnir subjsls thc apulicanr ro a civilpe,ralrroinor morc
<br />'hxn
<br />nv. hundrdl d.llah (S50q.
<br />l.rsosrftrorlh.rrurdy.urnrtcnr,royccswrhNnscstrslhcirvnc.oD,|cneriur.willdolhcsorlr'ilrh.nnkrut( n
<br />inlcnncd orollircn ior *,lc (S( 701t. tluincs and Prolcsi.n\ Gdc:']1. contxcktr ( 1.i...\d l-r\r doc\ n.riptly ro {n or nct of
<br />rhc |\ll.ny sho build\ oi i'n|a.vcs rhcNtr..nd sho dms su.h sod( hnnscll or hcrcltor rhroueh his or hcr osr..,rh].c\.
<br />pmviJcd rhlr \u.h i'nnmffrnkaEmr inrc'dcl or ollcEl Lreh l( lx,rclu. rhc h iHi'iE or in{rorcmnr i\ c,ld sirhi,{,( }cxr
<br />ol'..npLrion. rh OwE! Buikls willh3t rlE hkhn olF)vi'rr rltrl lr or d'c di{l mr lrild or i'npRnr nr nmpdy lirrlE ntrrBr*.f
<br />-l.
<br />rso*ncrofllrrnopcdy- arcrciu\ilcly$ raclingsilhliccnqlc.nrrrcr6r,.otr{.rrh.phjd(Scc.704-1.Duws
<br />rnd Pnni:snn cldc: l hc CotrtNnx c Li..trsc t-trw doc\ nor rftly h an o*nd .l trctf,rry Bho I'uilds or impratcr rhcrcnn.
<br />rnd wlm.onrntsforsuhpmjccrswnhoConrBcu(eltcnsdpururnrrorheConrracroisl-i(nsdljw)
<br />l,n'.r.mnt undd Serion
<br />traB&l8urgllfrlra.uaN
<br />DECI.A.BAIIO
<br />Ihcrchy rilirm tr cr nrnrlryolNrjsyonc (trhr f{,lk,wi'iS dcrhrn!i{trs
<br />-lh!\cind*illnuinr.inaCcrrilicarcotConsnrroscllln\!,ei.rworkd'.on!ff\ario.,acflovidcdrorbtsccrioo]7u]ordctitx{ cod.. lu rhc pdl.rmmc of lhc work for wh ict rhc Ermil is hsuc{t
<br />_l harc and will'nli'nain wolk.r\' conlp.nsart,n insurrn.c, ns r.quncd byScdi(rlTu)of rhc Llhor C-ode. fo rhc p.rbrnunccol
<br />rhc work foruhi.h rhis p.i,nir ir irsu.d Nlywork.^'...rp.nsarb. nsunmcc.rlcr.ftl policy numhcr orc
<br />c,.h, \ Fz*-nZtttn +Al-
<br />^,,,,*,''agf aoll 19 I /.2D1?
<br />I.cniryrlar inrhc lcri.nnrn.c ol rhc wort lnr whichrh( ntrmi n hsucd.l shallnol enqrlo, ant pc*or if uiyhanicr
<br />$.stob.com$rbFcrrolhcqo slonpcnslrion h*sniGlirmir. ula8mcrhd ifI \h,uld h.onr subicd lorhc
<br />*nrkcc' .onFns.rtun f,vn ions of Sccr ion :1700 of ric I i}i, Codc. I slull. fonh$ith .. rtly wnh rho{ nrovisions.
<br />WARNING Fiilurc lo k-urc wolkcs' onyEnrnlion covcrlgc is urlJwn'|. Md \htr|l {rlr..r trrr .rnplo}cr t] rininal P.triltic! and
<br />ir Jddirion h rhc .o{ rf conll.nqtnn. danra8cs 3r lrrovidcd fn rhc.ivrl fitrcs u| r, oR hundrcd Ihouend dollars ($1fi).(x
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<br />IECI,ASAII)!
<br />I hcnhy.r6.nu cr p.narlyofrcrjury rhor I ah liccnst lndcr t&vin,n orchrrrn e (commncins wirn Serion 7000) ofDivnion l
<br />ot rhc Btrsinc* 'nd Pmfcssions cod.. rid mv liccnsc n in tull rbre lid efldlA.b ?L(bGr.1
<br />".,, 5IaF3
<br />loNstalclaNlENlllNcitilNg
<br />I hcrhy rfln m uMcr Fnrkyofncrjury rhrr rhc'! h r co.{n'cri,n kndine ilcn.J lhr rh. Pcrt]lnrm.c olrhc woik l'.r which rhi\ plnnir N
<br />isrucd (Scc .liNr7. ( iv C )
<br />AIILII]ITNfDDIIASAUON
<br />I tmhy dlmuidcr Jxtrrlry.rp.rjury otrc ol lnc li)lk^vir8 d(hrnrions:
<br />l).nx'lirion Pcrn,ir\ A\hcnos Norifi.ari.n rcd(rl RcBul.tions ( lillc Jo.l'rd6)
<br />Il.qui'.Ll I rrtr f l Nd li(d(rr
<br />I ccnilyrhd ihc lidcrrl rcguhrnrtrs rcglding r\hcno\ rcn rlrc not Erdidhlc t,rhi\ pmFcr
<br />-l
<br />ccdilirhrr l h,rcru d rhnnmli.ari.nd {dc rl[rihcrt$!c iDfonn ri{,n i\c.n .r I tStcc hco,rrdy
<br />rnlinxn.c\ xtrJ Srrrd l:N\ rrlrling in!.on(d.riotr.mdhcrcb]rlrhrircr.prcs.n' ivcsof rhhCity
<br />rlxrr r.di,rrd |x,Nrly hr
<br />\rDlir!nr or,\srnl Si(nnl"ae4@)g4
<br />rnd Cndnr, r',.trrc.ut,n'h.qkJe
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFEFI Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsu lation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./6!. Lath 7-n-a 4-.9 '*wr* G /s.Au*--
<br />Brown Coal
<br />l\/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certil
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<br />FINAL hl'lilrV h^rya-K/
<br />Certif icate of Occupancy
<br />Notes Remarks Etc.
<br />-2 -l 2 /r'lu H
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