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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS owNtrR BIILDER Dlr_CAlr T|ON
<br />I hcruby rfit'n unrcr prnrlry t'r ]rcrjtr), rhar I a'n.xcnr lnio ihc Conrrdo6 L-icctrr lrtw f.r lhc thllo*ins ruvr lscc?0.11.5
<br />llurirc\s .trd Pdassion C(xlt) Any Ciy .r Counrt whi.h r.qunc\ r n(rnir k, con{tucr. rlrcr, tnF)uc, dcnd,s[ or Nfnr My
<br />t' rhc pn,lisi.rs ol lhc Cotrracior's Liccnscd lje (Ch3pru 9. C. nncn.r8 s[h Sc.riotr 7UX) .l Divi\im .1 ol th{ I}usir.s itrd
<br />P'ofr\si(,nsCoJr) orrhlr hror\tu i\ crcnU Ihcrcfiomand rhc br\i( li]r rh. rllc8cd $.mFrion Atry!n'bri{rofScrrionT0ll5 hrrn,
<br />rmlrrnr forrr$nnr \ubj.cr\ rh. dl,Fl,crtrrk, rcivilpcnrlryofnor nucrhrn l'1c h!fdrd dolh ($5(ll)
<br />-l-
<br />!s osmr olrhc prcItny. or DyenDloyecs qirh *r!cs 11rh.n vnc..nlftrnvnion. $illdo dc work nnd lhc {frrm is ftn
<br />lnrcnd.d d ofl.rc.l rff n'lc I 5(.7044, Busincs$d Profcssions Codc rhcCo rnctx s Liansc |-l*docsnorlpplyrorn.wi.ror
<br />rhc pDpcriy who htilds or irymvcs rhcmn. flrl *ho dm! geh n,Ik hnns.lfor hrrslf.r rhnnrlh hs.r hcr own c.rtloyccs.
<br />Dtovidcd rhrr s!.h nnptulcm.( a. dl inhdcdoroltcftd fo! srlc lll brsri rhc huildin! or impmvcmd t $Ll *irhinoi. )rr
<br />ot..ndcri.n, rhcOwmr Brildcr silltuvc rhc brrdcn oltmlin3 rhlt lr or sltc did nor i,uild or i'rwnlr rh| pmFny fitrrh. Nrlx,v of
<br />-1.
<br />is owncr of thc lropdy. afl cxclus ivdly co ta.ring sirh licctr{d ..nk(ktr\ t, .orlrflcr rlr |,Rrjd lsc. 7t!4. Bunrcs
<br />dl Ptrnc$fiCodc lhcConrrucro.s l-iccnse l-rwdocs nor ryflyr. rnowncr ollroncnywho huikls or inrlrovcs rhcrcon-
<br />rtrd who.ont..hli,su.hpn,icrlsnhrG'nta.i(,nrli.cn*dprrknrk"h.Coitr.r,\LiccnrUw)
<br />-l
<br />rnrcrcmfr utrdcr Sccrn .a &PC f(trrhisrcrn)n
<br />IABtrIAII:OIIEEITAIION
<br />IIjI:IABAIIA!
<br />I hcrchy rlfirn und.r rnahyolFajulyonc oilhc iollowin8 dLrlmrbns
<br />Ihr\rntrd$illuinrniirCrnificrrrolCon\cntbSclil,Ntr.f{tr*or[.rr.onDctr\](io,.r\pmvilcdturhlS&ri(rl?(X)olrhc
<br />tltxr Colc. lnr rhc ptrlonunce of rhc *q* lor $hich lhc |rcrnn n isu..l
<br />! hrk rnJ willmrinrrin sork..i conEnsrrion insuBncc. is rcquirenhtSccrion.lTl)OofrhclihorCoJc,n rh. p.rfonurt or
<br />rlt {ork ro' whi.h rhiiFirnir is i$udd N{ywo.kcrs .rnrpcnvlior in{rurEcarirr a'kl policy nunrn rrrc
<br />c,,,,i", a' Oh,- S...,.,{. lnr C ,-.,
<br />",,,'.r-,,,,*., XWSiqi{'?7ia io/t/t.?1-l
<br />-l
<br />ccnilyrhar i0 thc Frl'o mrc.olihcwortforwhi.hrhirp.rnrn is issucd.l sh,ll not cnut,y ony rcGotr inonynEoncr
<br />$ as t) lfmrr {bjd.r to th. *orkc^ .on1l)cn\d nnr bw\ ol ('!lift,nir. nrl ssrc rhrr if l should h.co rc subict ro rla
<br />w.lkcF.omFnsarnrnf.visioisofSc.ri.nl?(X)oarhcljknGxlc-lrhall,fonhwirh.\,mplysnhrh,{pn,vhiotrs.
<br />WARNINC: Irailurc r. eun sork s'.onrrcns.ridr covcnrs. is utrlrwtul. .nd sh.ll subjNr .r cnrloycr ro oininrlpcnrlrhs and
<br />civil fincs p ro onc hundrcd rhousand dollos (SIu).fiD). in d.mgcs as ,mvided for tlt
<br />s*rioo ]076 otrhe ljhor Cod.. i.r
<br />""", 3fa/r3
<br />I hcrcby dltflnundcr pcnalry.fr.rjury rhd I rm licnsl !ndc. prolist'n olChrpir 9 (conntuncin8 wirh SNrbn 7UX)) olDivisi(n l
<br />or rht llusi'rs and lrofcsio',\ Codc. url nryli.cns i\ in rlll lnEc 4IJ cr'ie.-l
<br />:cv5 182(3a*, ,f,6Ul a .-,*A <.
<br />I hcrcby rrfiri hdq pcnalr, ofperjury Ulr rh.rc t a ansrrudhn todin8 ascrcy to, rhc pcrformrc ofrh. wo.k for which rhk p.mar ia
<br />(skd (Scc 1097- Civ. C.)
<br />A.TILIIANI.DI'CLABtrIION
<br />I tmby rtilnundcr p.nrlr r- .l pcrjry .m of rh. lnllo*nA dNldrii($t
<br />l)cnnniion Pcflniis Aslf,(or Noriiicalin Pcdcrrl Rc8uhriorL (Tnlc.l). Pnrr)
<br />-Requn€d
<br />t.ilcrof llotifi calion
<br />I ccniry rhll rhc tcdd cguhrions Esardins ashc(osrcmvallrc nor lpplicablc ro rhis p!,Frr.
<br />-l
<br />ccnify lhlr I hav. r.ad lhk aFplic.rioD,n (ar.lhd thc ltsvc i.formrion Lscorol. I aE@ to comt
<br />fthy rlkrnc rcpic*nt.rivc\ .t rhNCi
<br />ly with rll Cityand Counr,
<br />ry lnd Coutrly lo cnts uBr dr
<br />inn(
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathin s
<br />Shear Wall
<br />[aming
<br />lnsu latio n/E ne rgy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />\ilrnFINAL I Mtt
<br />Certiticate ot Occu andy lr T -- t )-'rc/
<br />Not Flemarks, Etc.
<br />Set Backs
<br />UFER Ground
<br />o irrtrcc\ rtril Stut. Lrqs
<br />ah,v. rirn,ncdpnil,:nyfor
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