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BUILDING. INSPECTOR RECOBD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER AUILI,,ER DT]I,CARATIONiI hcrcbyrri und.r p.Mlty of FrJUry lhrr t on cxcnrpr lo rlD Connrcro6 l,ic.n{ Liw li,i rhc followira rctrsn rscc7(}:ll5
<br />Businc$ and P..ltsion Codt): A.y Cny ot Coutrry which requirc\ o p.nnir t, .oNrucl. altcr. imploYc. d. nrth or Rprir lnv
<br />smdue, prhrr. irs hsum.c. slso rcquircs thc allii.rnl lorsuch pfmir b rllc r sisncd \r{lcnrnr rhd hcor shc i( liccnscd Purulnr
<br />ro rhc Eoynions o{ rhc Conrractt\ Lic.nscd trw (chnflcr 9. ComnEncin! wirh sccrinn 7urc ot Divnion 3 orrhi Busnrc$ rnd
<br />Pmtcr\n,n\ Cod.)orrh h.orsh.iscxcmflrhcrcfro'nlndlhcb!\i\rdrhc,llcScdcxcnrPrion.A.yvn,hrnrnofs6tionT(,115bylny
<br />nppli..nr iora p.rn subjNts lhc arplicani h rcivilllcnalrtornor nFrc lh0n filc huidr.d dutl&s 1$500).
<br />-1.
<br />ar owncr or rhd prolrdy. or my emplnras qil h u.scs !r rhcn v,k co lncns&otr. sill do thc sotL fll rh- srmrm k ml
<br />n[cnLd or.licrcd for slc (Ss 70.14. Businc$ d ftofc\\ions Cod. Th{ Cofirnn\ I -iccns If,w docs not apply lo ]n oqtr ol
<br />rhcrmpcny *ho builds or nnpovc\ rh.mn. ind *tk) d{s such q()d( htns.lfor hch.lf.r rhrough ht or hcr osn cnDk,ycs.
<br />fhvilcd rh nrh nnrorcnEnh trc mr inrc'dLrl oroflt(n fot qlc ll, ho$c!.r. rhc ttuikli4 or nrytuvcrrnr is eH wirhi'r onc ycrr
<br />ol.onuhrior. rtr O{nd Buill.r will h.rc rhc bulncn of provin-s rhnr hc or \h. did tr.r huild or irnnrora rh. loFny fot rhe Nrrre of
<br />L sosrrrofrhcDol]cny.rmcxcltrsnclycoikr.rin!*nhli(n\cil..,rcrtr\r.cotr(nt.rih.fr.lc.r(Scc7011.Burnc*
<br />rnd lt(,tusi'nCodc:ThcC.nrn(ofsLi.cnscLnsdocsrorlpnlr-ro owtrctoinroPcnywho brildsor invmv.srhcrcotr
<br />rnd sbo.l lr&rs l'or such pmjccr *irh a Cofin.td ! ) Li.cr\cd NisurDr rorhe O,ntdr's Li.cnsc Ln$)
<br />I anrxc rtr uodcr scclio B &P( turrhi{rcnwr
<br />Dilc Own.|
<br />w()RxFR\', a-drliPl Nsa lloN
<br />IIICIAf,AIIA!
<br />I icrchy Jflnm und.r pctrrlryolp.iuryoDc o,lh. lnllosir8 dNlrrdn,ns
<br />Itulc dvillnuinrainaCcnirrarcorconrcdtoSclllnsurcr' *orkcrs con{cnsdi.n.$ toviddi,bysc.rion.1700olrhe
<br />kbor Cdk, ror rhc pcrlorMrcc ol the work lor which rhc p(nrir is i\sucn
<br />-l
<br />hrvc rkl willrnlinrain *ork.* .onPcnssriotr insuraNc. 11 rcquircdhysccrn,nITOJofrhcbb.rCodc r(x rhc lnlonMrcc o!
<br />rhc wo,k forwhichrhi\ p.rnir ir iski. MyworkcN $nrpcnslion in\lrricc.rnicr d Polic, numhcr de
<br />E / f,.RE ST /1//+rIt.)^,/4tZ f, /c-
<br />76oDo I i/2"(/zo t?
<br />I rcdili rhar nr rh.r..fornunccofrhc wort lor *hi.h rhi\ prrhir i\ t{rcJ.1shrllnor cmPloy, t lE^on inanyar0n.cr
<br />e a\ro be.om sub]cd ro rhe *orr.rs co'nP.ns.rnrn hss olCdlilonia, nd rgNc rh,' il I should hccom \ubFcr ro rhc
<br />worksr cory,.n\arion ,iovisions oi scclion l7m of lhc ljEn Codc. I \rull. ronhwilh .onDly wirh lho€ prcliii.ns
<br />WARNINC: failur to $cuft s.rk rs co,npcnsri.n .ov.tu8c is unlawlul, and shall suhl.d drr cnDlor. b cnninal Ir. his aal
<br />cnrl nnc\ up r. olc huftdrcJ rhou\.nd dours (tlw.L()lr, irr rd iri.n t, ih. crv ofconrPcnsarn,n. datulcs rs pruvidcd lbr lhc
<br />Sccrion.l(,7oofrhc LJtur Codc, 'ntrc{ r'J dtoltac} s Ir(
<br />,",",\tiTtzot( ^,,rX Ezerr ur'ooD
<br />IICINiIDIONIIASAf,
<br />I]ICIATAII!]N
<br />I hcEby nltirD u tucr n Mhy oi rcrjury rhar I n li.ctrs{ uMcr tnovhion of Chnpid 9 i.ummncirB with Sccrhn 7(xx}) .r Division 3
<br />or rhc Bu*nrs,nd PmfcssionsCodc. ud
<br />'nyliccnsc
<br />i\ ii tull roMd.rtcd
<br />lYoz?z
<br />a/B13tV ftNE\r r. 4t DoLEo,r
<br />COXIIIILCU!]NIINDINGA{iENII
<br />I hcrcby ariirnr under rcmlly or p..jury rha hcE is s .on$dcri,n kDdins nsctuy for rh. FrrollMcc of lhc *or* for which rhir lErnil is
<br />issucd (se 1097. ci! c ).
<br />drftrc N:LDEc!r8.tru!)!
<br />I h.a$, !frim unncr pcnahyofF.jury onc orihc rollowirg ncchr.rions:
<br />D.trx,lfi n,n Pcflnils.Asbcslos Nolificalion Fslcral Rcgxturnnr (Tirlc 40. Pln6)
<br />Rcquncd kllcr oiNolilEari{,n
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certil
<br />FINAL v-/( -g-/,/z {,^b (q/
<br />Certificate of Occupancv
<br />Notes, Remarks, Etc
<br />SLAB Floor
<br />tJ*ld r AJdn$.
<br />-
<br />-l
<br />ccnirrrhd rhc r.ddrdr.8nlalionsESadinS ish:srrx rcnnlulrrc mrimli.dhlc ro lhis Projccr
<br />-l
<br />ccnilirhd I hrvc rc lhis lpplic{lion o.d shre lhn lN d,vc i'nnnniri, i\.oncd.lasrerocodplywirhiliCny! Counr,
<br />nl'm!!cs mJ sr c Lxw, mlalne ro b'ildi.s connrucltr'n. srxl hcrcbyaurbriz. rcUcsntrlivcs (,rrhn Cny and Counly lo enrer uPon ltc
<br />".;.,t,,,,;,",
<br />Pemi,ee*mc,pr,n,): ZBZult Lloo P
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