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BUILDING. INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS OWNBR BU!LDER DEI,CARATION
<br />I h.rcby afirnxndfi pcn,lr, ot ncrjury lhar I ! excnlpr tmnr lhc Conkr.roF Liccnrc L,w lor rhc tollosing rcrsotr (scc.7rll5
<br />Businc$ rtol Protsnnr Codc): Any Ciry .r C.unry whi.h ruqun s , Frmir lo ond cr. slrcr. inProvc. d.moli\h or rPan tny
<br />{rucru.e, nrior ro irs issuancc. also r.qntcsrhc applicr tu sn.hncrmir lo filca sttud n,rcmn' lhar hcorshc n li.ctr!.d ,ur$Nnr
<br />ro rh. pmvisions oflhc Conrracroir l,iccoscd l-,w (Chrfld 9. Cdnnnrn.ins !ilh Sccrn,n 7fi)0 or Divisiotr 3 ol lhc Busines aid
<br />Pmfcsions Codc) or rharh. or shc is.rcnlPt lhcrcfroo.nd rhc bosis for lhc allcgcd cxdnrrrion AtryriolarionofS*ri,.70115 byntry
<br />rrpli.anr rorap.mn subj(t llE ipplicanrt, scivil!.nsllyornor xtr rh.trfivchnndrcddollarl$5flr)
<br />l.a\ ownootrhcFruFcny,ornrycmployccswilhrtrsc\!slhcisolcco'nPrNnrt,n,triudorhcwork dihcdnrrur'(tr.r
<br />inlcndcd or olTcrcd for elc (SE 7u.1, Burin.sr rnd ftot $iois Col.: Thc (-oniractn \ l-iccnsc Dw dor< nor arDlv k' an okkrol
<br />rh. |,ltEdy who t'uilds.r iqnovcs rhcNtr-,Jld who dms \u.h *orl hinNclfor h.lsclfor (hrouSh ht ot hcr o*.cmplolcc(.
<br />pn,r idcd rld $ch inlpn,vc :m m Nr irtrcfrlcd or oficBl a(tr slc ll how.r.i rhc hoildine or i'Jpbvcmnl i\ \oltl *ir[i'r otrc rnr
<br />ol.oD[Ltion,lhc Oqncr Buildcr sill hr\t ih. burdcn ol PmvinS rhsl }r or shc did mr tNikt or i'qnrR rhc Pm!.n, tor lhc nDrlnror
<br />- l .A"uf(.oIh. nn|{n).,n'c\'u.'\c\ n.i'rr'ng " h hrctr{J.rnrh!rnr n,$r.r .rrhcF}11is.! r{!. tlusm..
<br />rnl Pnlissbn cl e: ThcCont(ntr's Ltcnsc Lrw docs trol (J) yro rnosnc'ofnhlddysho buildsor imlrolts rhdrcon.
<br />ind who.oma.tsrnrsuchpn*cr\wirhaA'nhci{(nli.ctr*dtursuMrrorhcConrracroisl-k.nscbt).
<br />I {Dcxcnrpl undcr Scclbn-. B. & P
<br />IIICLABAIIAX
<br />I hcrch! amnn undd ,cmlry ol FIury onc of rhc lbllo+ i'ls de.lrrr i. s:
<br />I hrvc antl * ill Minldn ! Ccniliclrc of C.ns.m b sdll lNurc hr sorkcN conrpcnr nrn. as ln,lid.d fo. byS(rion.lTlx).ftht
<br />ljtrr Gxi., fr, rh. !.rfornlmc o f ll'e wori tor *hich rhc n rmir il isx.d
<br />-lhovc
<br />and willmanrl{nr work.^ .onlf,ns0li.i insur.n.c. rs rcquircd $yssri{ -l7cn .r lhc tjtx, Codc. lor rlr ld(trnrn.c .i
<br />rhc Norl lbrwhichrhn pctuii ir issncd Myq..kcs comptn$lon insurrNc crtridr,nil Fli.y nunbc! are:
<br />-l
<br />ccnil, rhar inrh. pcrturmn.c ofrhcvork litrwhich lhh tcrmir i\ issocJ.l \hrlltror cmfl('ynnypc otrinrtry'nrtrNr
<br />q, rsro hc('N suhjccl Iothc workcrs'compcisrri n hwsofcrhfniid, r a8rerlNrill \k,!ld t*(rm {bjcd rorhc
<br />tci t, dimin(l rnullics and
<br />$orkcn .onrpcns i{nr pmvi\ions olS..rn)n:lT0Oofrhc tjtxtr Codc.l shall. tonhwirh.onlP ! $!
<br />IV,{RNIN(: Irrihrc ni *.ur. *1rlc^ .onrcn{ riinr co\c'i!c is trnL*lnl
<br />.ivil 6trc\ up b onc hrndi.d th.usrn,l doll(l (SlOO.U)o). iD ad iri,
<br />sccrion :1076 ol rh. trtx, clxlc. intcrc(lnd lrrorrcy\ Lcs2e4
<br />DECIdE6IION
<br />I hcrcbynilnmuBlcr pcnrlry.rFrjury rtut I rN licctrton undcr pmvtbn orchlprn 9lconmEncins *ilh S.crhn 7{xx)) oiDirni.n:l
<br />.r rh. Bn\nrs rnn Pmh\{ions Cinlc. aid nvliccne il i'r full forcc alld cit{t
<br />,,,,," f-4-to
<br />ca!$IBlJqrMNL[NIllNGSliEXq
<br />I hcmhylafir under Fnrxyofp.tury lhal rhcrc is d condocri,n hndinB rgcrcy for lhc Pcrfornrancc orrh. work for which rhn Fnnir ir
<br />irsucd(Scc 1097-Civ C.)
<br />APPI ICANT T)ECI AR TION
<br />I [nhyantmhdcr pcndlry.rp.rrury onc olrhc lollo*in8 dccloErn,ns:
<br />lxmolnion PcirnnsAslE(.s Norifi .arn,n F.dfinl R.Sxldrions (Tirlc 40. l'an6r
<br />Rcquncd Lcttc! of NolifEdi,n
<br />I ccniltihd rhc ltd(rl rcetrl11i,'ns r.EadirA i\h.ro\ ronn,vrllr or nftll.rhlc r)rhis nnlrcr
<br />I .Lnify rhlr I hlve lcod rhn 4Dkd riimndd {rrcrhrr rh.rhir. lnn i,!, n..r..i lrer.cn).onrPlyuirhlllCiryrtrd Coufrr_
<br />ordi'rrtrcc\ rnd SfurcLr$\rcl ing bhui n,!ofrh$ Ciry Ml Counryi) r ror uJi ilt
<br />$orr nrnri{nod rn,jrc'ry lnr ffNdi([
<br />o,, 1= 9-rI
<br />Set Backs tX,/
<br />Formsi Steel/Holdowns \{,1/.v7
<br />Ereclion Pads tg\"/7
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathing E-7.6-tb BZfl7 \a4 tto 6^h
<br />Shear Wall t0-ll..Lb GTar
<br />Framinq .,4,.2 -.=
<br />lnsulation/Eneroy lv1 "- lo I l7<--
<br />Drywall lolbht'&ncrt>/n-
<br />Ext./lnt. Lath ro/ii/,*Gzntz+
<br />Brown Coat aZala 42s,-<t "3DMasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Reporl
<br />Engineer Final Report
<br />FINAL ./24-/R ,/)72-21 n-, loJ
<br />Certif icate ol Occu anc 6-/c
<br />Notes, Remarks, Etc.K-Zr-r Dtf
<br />2
<br />SITE.WOHK
<br />Flood Zone Certil.
<br />ApDlic.,l "r Asent SlS.{luErt(
<br />P€milee nsnE (pnnl)l
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