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.BUILDING-
<br />INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS
<br />Set Backs 4/T.f//r f<ulovn-/tu
<br />Forms/Steel/Holdowns 'ito*|rr,'Er4Atro 1tu-
<br />UFER Ground 4/Ld//k z t/tfu'/h-
<br />SLAB Floor
<br />Subf loor/VenVl nsu lation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<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 Certif
<br />ffi- LAUA iltT#{"\ dLm A-A<t€st-t'z/ru/l<'5Y<
<br />tfz{xii
<br />lL/ltl6 2D((FINAL
<br />Certif icate ot Occupancy
<br />Notes, Remarks, Etc
<br />OWNtrR BUILDER DN!-CARATION
<br />I hcrht ,fnnn und.r l..llry ol pcrjrry rh,r I m crcnrPr lmnr rhc cotrtrrcror' l,itit bw for rhc r'u'win8 rclv)f, rscc 70:rl 5
<br />Busin.s\ i P(ncr\ion Codc) Atry crl, or counry wh*h rcquir.s . Iirnir ro mnslrucl- alrcr' imProrc. dcnrlhh 'r tPiir !n,
<br />socturc. l,tnb ir{ issxin.c. aho rcqrncs rhc +!li.nnt lor such |rnnn ro filcn sisEl.anmtrl rhar ncor !h' $ liccnscd rtrrurnr
<br />t, rhc lorisions oi rhc Conlh.rofs Li.cnrcd hw (Chnprcr g Co.nncNifs sirh s'dion ?0(E orDivision:l olrl'i Btr\in's 8trd
<br />Pn'rc$iotrsCodc)orlh h.orxhc iscxcmpl lhcrctonrand lhciash iorrh. rllcgcd cxcnrPlnnr Anvviolntionofsc'tlJ'70315hvliv
<br />,ptlicrtrrri,r! pclmir s$i..rs rhc rtpliconr lo scivilpcnrltloinor morcrhtn fivc hundrcndo!1.* (55m)
<br />-1.
<br />ownfiofth.!rcJlcny.{n.ryc lroyccs wirh ulScs us rh.n sh ..mpcn$rnrn. Eilldo the $o.k ,ild rhc rlMlnft ir nn
<br />inr.nk\i1 orofrcrcdforsrlcrSN.T0.l,l.0lsincslndPtuLs(i(NCodc'lhcCom'lcroisl-icen\.trrtloc\trorrprlvhano*mrol
<br />rhc lxiFny wh. huildsor i'r+ruvcs ttEen, ml wh. das su.h wn* hnn\clfor hcrsllor rhmugh hh or hcr osn cmpl')Bs'
<br />p!.iid"d rhur "!ch inpmerEnh rc tu, iNcnhn or ollct{ fn eh.lt hwcEr' rh. hurldinS or inlmtmtri is sll wirhnr oft }c[
<br />;i.otrD!.r iotr. Itr O*tcr Btrildcr will lN! rhc hulci or pmvinS lllll hc or shc dn not huiH o, nllpmvc dE pDncnv rrtr thc luqns of
<br />l. r{ owncr of l hc proP.dy. rtrr clurilcly (nrh.rirrg sirh licctr{d ..nt0croF b con{d.r rh. Irl'imi (S" 7(x"1' llusn's\
<br />arl ,'nrG\ir Colc: lhcC.trtrLcktr sLiccnsc Lrs{to.s iordltnlyr(' anos cr ofltnrntrrv*ho huildsor imprcvc\ ih"con'
<br />rftl *ho conhch r.r such pr)jccl\ wirh r G, r r.ron n liccn*d Nhumr h rhc C. rm.nn\ Liccnsc LLw ).
<br />-l
<br />inrcrenpr undft sc.lio.-
<br />wo{xoRs' (:()MPIiNsaTl(}N
<br />DICI,IBAII9!
<br />I hcrcby rltnnunn.r pcnalry orpcrjury onc oflhc iolLwing dclardiotrs:
<br />I hrvcnndwill nBinrain rccnirKolc.lconsent k, s.ll ltrsuN for {orkc( .onlrcnsation rs poviden lor hvSc'rion 1'7(x}orrh'
<br />L.hor Corlc. rd rhc p.rlormncc !l rhc w.ik tu whkh lhc P.n.n it irsucd
<br />-l hr!. rid uillnliinroin sorkcF coruPcnsariotr insuruncc. a\ rcquncdhvSccrnrnlToOollhcl,horC'dc.forlhcP'rr"rfrr"or
<br />rhcso'krorwhi.hrhispermiri1nsucdMysorkcG.onpcn\nrioni.{rancc.antr dPoltvnumb.ru.:
<br />Fr.lr{
<br />l.cnillrhir ir lh. p.rro nnrn.c ol lhc sorl tur *hich rhr\ ,)c nil i\ issocd. I shull nor cD
<br />so r\r,) h..onf, \uhjccr brhc {orkc^ ..n,F n\rr!{r hs\ ol Crlitui,iir. rtrLlUr+-rhrr,ll
<br />ro'k.'\ conl|rcn'x1iD |n,nl.i,1n\ fl Sr.tron 1r(x).lrlt I rtx, Cttl..l nill.lnnhsirh
<br />W,\RNIN(; Ir.il'n. n) ro(urc wnkcrr conlltrD.rrtrrr (,vt'dsc i\ u,l vll xnd
<br />.ivil fitr$ !! n) onc l ndrcd rhouslnd noll$ (Slulux)). ir a(ldirio t! rhc cdil
<br />sc.riotr 3076 orrh. utrr (tdc. inlcrc( and unf,y r llts
<br />"",",1:r-lL
<br />I lrtohy dllnnr trndd FcDrLlyolr)diury rl r Irr lic.n{(ltrtulcr lv.\i\ofolChrPr rnh sccrion 7(xxl) olDivisior.l
<br />ol rh. Ru\i't\\nn l'r'n.\\ o'N(i,Llc. rtr(l orv li..ns. l\ in tull h,.c n .lr.!
<br />!:I)N$BII:IIOIIL!!IUNT.L!iEN.CI
<br />IhcNhyntlirmundcrFn.kyolI'criutyrhnrrhcBisn..n\ln'cri'nhdi'r8r8ercvfitrrhtP$ronnaN.olrhcwotkr'orshichrhNfEnniri\
<br />is{rd(sN 1097-( iv c )
<br />lr er! NJnr:
<br />-
<br />l.ndea\ Addrc{s
<br />-
<br />ATTUqNLDEELAEAIION
<br />I lrrhyrrnnnndcr r.iJhy.lJ)crjry orc ol rhc n,lL,wirA rlcclmrionr
<br />Dcnx)lnion Pcnnits Ashcdo! N rific{rion l:c,lcrrl Rcguhtn s ( lilcll). Px O
<br />Rc!uirctl Lcrlcr of No(ili.ari.n
<br />I ccnir!nr ihc tudcrrl rcFul.iion! rcs&tnr! r\lt\
<br />l.cnilt rhrr Ihx\. R l rhi\rttli.rri,n, Rl{xr.kJ.onrtly qlrh rll Cry rn,l (itrtr y
<br />udiMtr.cs nlSr rcl. s\rch|r!l.huiLdn,S(o {olrlrl\ Ciry md Coutrry h cnicr uBr rlt
<br />xhovr r ri(ftd pnipcnyl.r i'NJtrrrirnr
<br />A[Dlicrnl or ,\[.nl si!o,lurc
<br />!'€mil(c n,nr rprinl):
<br />2:s=d
<br />Erection Pads
<br />Ext.i lnt. Lath
<br />I nctr\r ctru -
<br />,,,,e 7:/=l/
<br />f-r
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