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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER AUILDER DF]LCARA'TION
<br />I tercby allnD undcr Dcnalry.f ri..jDry rhar I m.r.mDr rm,n rh. Contrtrdon Li.cns l,$ (,ihc rollowinS rcasn (Scc .ll5
<br />Busincss tud Prcf.ssnrn Cdl.): Any Ciry or Counl, shi.h rcquirc\ x pcnnir b .onntud, alrcr. imptovc. dc.Dli\h or (nnn ,ny
<br />srudm. priffro irs tsu0tre {ho rcquncslhc !!pli.a,l tor skh lErnir h rih. si8rcd (dcmnr rhar heni sh. is licc.scn Pusu.nt
<br />ro rh. Iln,v^n,n\ of rlt Conra.lols Liccncd liw tchnpicr 9. ConmErcing wirh Sc.tion TOfiJ ol Divhion I ofrh. Bu\i.cs rnd
<br />Pn'tisn,rscdlc)orlh.lhcorshcisexcmplrhcrclromlndrhch\iatnrh.rlLtcdcxcmptnnr.Anyvn,hiionorscctionT03l5hyrny
<br />aptliclnr iorr F nrir subjcchrhc amlica.r ro a.i!ilp.nalryornor nnmrhr livc hu ndrcd d.llm lsnn)
<br />l, d .wmr or rhc pnFny. or nry cmtn,)es wilh wrscs us rhci! s,l. compctrsrtiotr. will do lhc so.I ed tu ntu1w s r{
<br />ift lcd or olTcrcn lor slc (Sa 704.1. BtsnE{\aid l)iJfcsnN Gilcr ThcConlncrois l,i.en\e l,tredocsnor0lllytoatro*Nrol'
<br />rhc nmrcny *h, brilds or in{,n)vcs rlEmtr. lrd qho dfts sucn sork hinsclfot hcrscltor lh&lah hk or hcr own c'nployc.s.
<br />pror cd lhur such imporcmnr\m ni.b Ldorofi.rcdforsh ll howcrr. rll. tnildin! or in{lowmnl G eld wirhin .nc ,to
<br />or.o'nphoon. th. ow.cr Buildq will hNt lhc burdc. of l)r,!ios rhor hc ur sh. did.oi buikl or inrprove Lhe pnr!.ny lor tfu Puilns ol
<br />-,.
<br />ff nu'ncr oI rh. F,pcn!, :m cx.lusivcl, cotuldi08 sirh li.cn*d .ontrtn\ b .otr{fl.t rku pr.l$r ( S.r 7O1.1. Btr.irrcs
<br />ind l\ofssnfl Codc thcConlrscrorst-icriscl-rsdo.snorrpnlyro!no*ncroltn)Il. y wh. huildlor iDlrovcs rhcrcon.
<br />lnd who conrrk for such trrj.lts wirh ! ornrru(ro( n liccn$J ^urN rorhc('onracxni l-icen\c li*)
<br />-l
<br />rmcrcmar utrdcr sccri
<br />D.le o*mr
<br />WORKIiRS' CI)NIPEN.ATIoI'i
<br />DEI;ITIBAIION
<br />I hcr.l,y umlnoodc. p.nrlryotn rjuryorcof ihc r'ollowin8 dcch,arion\:
<br />-l
<br />tu!. dl will mintri,r r Ccnificdc of Comcnr lo Scli lnsurc Lr $orlcrs .onf.nsrnnr, os ,rovidcd fttr by sdion 11?00 oi thc
<br />kntr Codc- ldrhc n rrornrn.corrhc wort lor*hichlhc ncrnrir h issucd
<br />I hnrrrnd will nri air sorkcrr co'npcnsari,n, ntrunmr. A r.qur.d hySc.ri(rl7lX),'frh.l-ahor Codc, rorrhc ncrfonmncc or
<br />rh. trurk ror whichrhi. m,mtr '\ trtkJ Mv tr u t(v .ommni0rx $
<br />conrr ' L&ne /
<br />urarcc cadc, anr rolky nunb.. dc:
<br />Poli.y Nunrbc. '
<br />Ic.nifyrhiinrh.p.nirnurccol'rhcworkturwhichlhnpcrn,ir n i\\ucd.I slulltrol carPloyrny P.ron inrnynr ncr
<br />$ s ki h..otrf, uhjcd r0 rhc Nork.rs .o p.n\d idi hws ol crlilirirrin. ini +rcc rhJr il l sltr,uld h.oN subJc.l l,i rhc
<br />workcr.onrpcn\rinn,Ifuvni(,nsofScdionlTtX)ofrhcLlluCodc.lshrll.lnnhsirh.onlily$irhrhosprovhi{tr^
<br />WARNIN(;: F,ilurc b ccurc $ortcr .o'npcn{rn,n $lrflgc is unhwful. snrll su},]ecr J, cnlPl.yd k, Lrnninrl PcBlri:\ xnd
<br />civil fitrc\ nf b otrc huDrlr.d rhourrnd dollm lSllx).o(X))- in:l(tl i(idrorhc.ri
<br />ffi;:,"'"'* '""^":::!{ttri:::;(=
<br />I hcrcb,arfi, undcrrEnrhyorpcrjryrhdl3rli.cnscdundcrl"ovisionofChaprcr9(.o'nMn irtgwithScclion7(xr0)orDivi\i.il
<br />of rhc Businc$and Pmrc$ionsC{rlc, dxl my l'..n\c ir i'r tullntrcd d cli.cr
<br />-D-to4zV(
<br />)A*",.4,f2,+/tt (.,,,,,.,.,,,. ><b;It-e"Z
<br />CON,IIBU(:IIONII'NDIIC.{IjENC}
<br />Ih.nlJyrfi n uM.r t'ctr,lry olFrjury th{t rhcrc h ! conrlruclhn knding r!.tuy ror rltr Frlornutrcc olrhe work lbr qhi.h rhis F-nnn t
<br />issucd (Scc.309?. Civ. C ).
<br />AITUCINLDES.AAAIIAN
<br />I hq$y inim undcr p.nllry otr.lury om or Lhc rolhwnrS dRlarntions:
<br />Dcmolition Pcnnih A\trsros Nori6c bn F.dcrulRcSulario s{r,llc 40, Pnn6)
<br />-Rcquircd
<br />lrllcr ol Norili.orbn
<br />lr.diltrhrr rhr Ldcrxlrcgulnrtr rs rr!trdirg r$lt(o( rcmrvnllc nor rfl,li.rhlc ni rhi\ txiic.r
<br />l.cnili rhrr I hrrtrc lhis t'tlicrlonlnri..\ rtr.lSr"r. trssNldirE ro hu
<br />ir r,'rl {.i.r rrrr.)rri\. riL{trr!r,l ^.r"r.r I r!tuLhdntlyqlrhrlLCir!r C.rdrv
<br />r.|nr\cdrxrirr\ otrlr\ Ciry ini (ind)_ ro. n.r u|ln rlr''[;;--
<br />-9Lq<Z
<br />fut,t
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq 'o/41 k t 'r/Y|[>rA-/ tt-
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Cefiif
<br />FINAL TrlqfH -/1L'
<br />Certiticate ol Occupancy
<br />Noles, Remarks, Etc
<br />Set Backs
<br />Brown Coat
<br />tl
<br />/,w//y
<br />xbvc nrtrri,nrn tnJlnf lnr
<br />l::::"":::;"::x-
<br />A.
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