|
BUILDING- INSPECTOH RECORO
<br />SITE.WORK DATE ID/SIG.OWNER tIUII,DER DELCARA'I'ION
<br />I h.reiy nlitm undcr nrnllry,n p.riury rl l am.xrnu llom rhc (nnrrrcios t,icensc l-rs turrhc lnllosin8 rcrqin (S(70315
<br />Burincss rnd Pn'fc\si(m Codc): ny Ciry or Counry *hich rcqlircs x pcnnir t, .on{tucr, dltcr. irnoroic. icnn,Nh 'tr rlrn .'ny
<br />nflcfur., prff ro irs hnr0ncc. lho rcqutcs rhc aPplicrnr for\uch Frmi o tha ri8trcd (rcnrnr ihat h..r shr is li.cnscd puruanr
<br />t, rhc pmlirions of rhc Conr crols Liccnsd Lrr (Chinlcr '1. Connn.nci,r! *irh S..rion ?(XD oI Divnion :l ot rhc Bu\in.* md
<br />Pnna\\io trs andc) ur rhd lk or\h. hcxcnDl lhcrcirom and rhc6r\i\,nr rhcdllcscdcxcnuior. AnrviohiionofScclt ?0115hyrny
<br />!|)plicadfora!.nnirsubj.clsrhcrrpli.rrha.ivilpctrrkrorn.rmrclhrnlilchundrcddollrs(5500)
<br />-1.
<br />a\ oqnd ol rl{ !rJr.ny. rtr my cnDloFcs *ilh Nascs r! rhcn sh conDctri&on. vru do th! \ork ard rhc srtubm n mI
<br />i, .ndcd or oficrcd lor slc lsa 7()4'1. B!\incs lnd Pmltsii,ns Codcr Thc Cotrtrctoi s Liccnsc l:w d..s nor npi'ly h .n owmt of
<br />rhc pmpcrr, r'ho buili\ or inpmvc\ rh.N,n. &d sl.()doc(suchftlkhnnrclforhcrcll.rrhroughhG or hcr own cn{,lo}cc\-
<br />!tuvidcdrhd.u.h imrmwmnhNmr inrctucn n oitEt for$h llhow.v.r.rficl ildin! or nnroEnEnr is $ld wilhin onc )rr
<br />of.onllLrion. rlk Oa rAuikldw n rc lhc hurd.n .l l[Nnl3 tll hco shc did nor hildori'npi{,!t ihc pbltny f.r rhc f'u.rnc of
<br />-1.
<br />tr(oNncrolrhc !mn!ny- r'ncrch\ncly conta.rin8 siih liccn\cd.onrr&xn lo cotrnn'cr rhc nl,rcd lscc. 7(I4'l.lJunncls
<br />rid Pn,rl\\i Codc: Th.Cotrtidois t-iccn\c l-aw doc\ nor rpnlyb rnownoof|lo!.nyqh(, huildsot imP'orcs rhcrcon.
<br />anl *ho conrE ( rhr su.h prcj&6 *irh n Crrftacro( s) lrctr{d rg,sEnllorhc (bntaltr's Licc \c tiw)
<br />I nrcrcnrfl rtr.l.r scrrn
<br />)
<br />b",. r/22/2ot( o-.",
<br />I hcrch, nr'linr undcr pcnalry oa pcrjr, onc orihc n,lbwing d.claiario.s
<br />Ihrvcelwillnri 0in{CcnificarcolCo.\cnrhSclfl.\ficiirqortcr'compcnsarion.rs pmvidcd Lt by S$riotr :17(D o l'lhc
<br />Lrhn codc. r(tr'hc p.rrornDmc.frhc wort Inr *lich lhc p.mn n nrucd
<br />rhc sork l.r which rhir Nflnir is isucd Nr, *orkr! .otunci\rtoi \ufuffc.Micr !d Fniryntrn,hcr rc
<br />P.li.r NunrEur l*Irt \
<br />-l(nifrrhar
<br />h rhc Fnoi,rurf,c.frhc uork iorphDhthhFnnir is ksucd. I \hrll nor c'npl.y nny l[Fotr in any trtur
<br />$ .\ ri t$om ruhjccl r. rhc *orkcrr compcnvrion !ra\ orCrlir(rni( rnd isre rhrr ifr \h.uld hcc f, \uhicd ro rhc
<br />s.r(cr\ conrp.nsnrion nmvi\ions oI S(rnnr :1700 of rl[ trhtr Codc.l nnll lndhwirh dnnnll {irh rho{ fmvhions.
<br />WARNING' l;d,lurc to ecurc $orkcr\ co'npcn\rrnn cov.rrEt is u l.$ful.shall suhjcr a. rnDk,,cr ro dinlnnl|cMlric\ oM
<br />.lvil litrc\ tr| k, otrc hundrcd rhox\trnd {lollrrs l5!(X).(XI)). 'n dirn ro .o( of.otrDc){io., drtugcs as prolidcd nn rhc
<br />s..ri, 1076olrh.Ialltra(nl. inrcm( md dktr'{! \ tcc\
<br />/azleow
<br />I hcrcby rfirm undcr F.alry or tf,rru,y thdt I !D li.cD{du crprirni{'fl Chrfrcr 9 (connncrcinS *ilh Scdion 70U, orDivsu l
<br />ol rhc Busi.cs Md PDlc$ion\ Codc, and ny li..nsc i\ ir tull fora Md cilccr
<br />l-ic€nsc Ch*:-Liccnsc Nxnh.r:
<br />D.le:- (onlmclor.
<br />CONEISI]!:II9IiTE DAI.{CENII
<br />I hcEhynrfir undcr rcnrlryorFrturyrhar rh.rc k a co.(ructio. lcMirs uscn.y ntr rh. Pcrturruncc oflhc {qk nn qhich rhs Fmn is
<br />i$ucd (Sc. 1097.Ci!. C ).
<br />AIILIEANIIJECI.ABAIJIN
<br />I hc.chy B,lim oidcr p.nnh y of pcrjury onc oflhc tulowins dccloari.ns:
<br />txmolirioo Pcrmih Ashcsros Norificarn,i Fcdfal Rclulalions (tillc 40. Pan6)
<br />-Requicd
<br />l,crr$ oI Noliarc ion
<br />I ccniry rh{l rhc lcdcml rcs!l!ri,,i\ dstrdina asb.n.s rctrFvnl rrc mt lnplicahk b rhis pm}Il.
<br />lcc 'rirhJrltulc,cJd,hi.Jmli.dtr4inJq$rly'hcrha.irF,n'J'tr'nnc"ncd IrE'mh,^md
<br />dtr'J1,F rtul sr0rc trsir.l .rt h huildinF \ nFrtor{ion. .rnd- nc'ci, surtFh/. rcIlrc{nrd''cs ot tht Cir
<br />il:.,ff-il:"*''W%/M\-.-..--, D..
<br />p.mi,rtune,prin,,: top'e I UllJ*u't€N
<br />Ly wnh allCnynnd Cormy
<br />y Md Counlyto cnlcr ull)n llE
<br /></aeho 6
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads I .)t*./
<br />UFER Ground
<br />SLAB Floor \
<br />Rool Sheathinq ct),-.
<br />Shear Wall
<br />Framinq \( t-,.'
<br />lnsulation/Eneroy
<br />Drywall I )I 74)UI \
<br />Brown Coat
<br />Itrlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Cenif .
<br />FINAL t-z\-/)
<br />Certif icate of Occu n
<br />Notes, Remarks, Etc
<br />COMMENTS
<br />/a-D/
<br />=,,4/"t1
<br />Sublloor/VenVl nsulation
<br />'V//r/
<br />4x^L'tL11
<br />Ext./lnt. Lath
<br />/l\u$l\\\
<br />t(
<br />Ifid.ar Nom _
<br />I.ndcis Addc-'_
<br />I
|