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BUILDING. INSPECTOR RECOHD <br />SITE.WORK DATE ID/SIG.COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVlnsulation <br />Rool Sheathinq <br />Shear Wall <br />Framin s <br />lnsulation/Energy <br />Drywall Y/rz/rt'\>W L-1,1 4. <br />Ext./lnt. Lath <br />Brown Coat <br />rYIvlason <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif . <br />n <br />FINAL Q//o//l ,4H.L/, <br />Certilicate o, Occu pancy 1 7 =r -v/ <br />Notes, Remarks , Etc <br />OWNER BUILDER I}ELCAR TION <br />I heEby nfltn undcr lcntrlly ol pcrjury th l trflr crcnrtr ironr lnc Cotrtr.dor' Li(ne L!* r'or thc iollosinr tcasn (Scc 70lllr5 <br />Bu\incs lrn Profc$i.tr Codcr Any Cit, or Courty which rcquircs n Fnnil lo sr{rud- alrcr inrpDvc. &nxrth 'r rcn5t rn, <br />nru.rurc, tiF roik i\suatre. sho r.qxiftsrhc lPdi.anr tor \!chFrnir ro lil.a\t'rd iarcnf,nr rhnr hcorrh. is hccnscd NrsuMr <br />r) rht nmvkn,ns ofltr CoorEcnr s l-icen\cd ljr lChiprcr 9. Commcncins rjrh Secrn,n ?o0O or Divi\ion.l or rhc Busind$ rtrd <br />Pofcsrions Codc) or thrr hcorshc kcxc rflthcr.lio dndrh.b{sisforrhcrllcecdcxcnpridr AtryvnnllionoiScclinrT03l.5hyrny <br />+rlica tua pcrmir suhjccrslhc applicanl roncivilrcnakyolnol nDrclhrn rivc hundrcd dollar(ts(xl) <br />I.isoqtrcrofrhcroFny.ornryenrDlorr.(wnharscs,srh.irslc.onp.trs.rion.willdorhcwo itrdrh.srMrchml <br />i cftlol orofieredlors0lclSc.7O44.Busim$afldPmfc$ionsCodc:lhcConlEcloisl-iccn*Ir*doc(n.r!pnl,brnowncror <br />ihc pmlEnl, wtk) builds or iqrovcs rh.M[ nnd wh) drrs sxch kd( himr.lfor hcrslfor rhrough hi\.r h.r o+'n cmployc$. <br />,iovidcd rhrr ru.h ihpohtunrs e *n incid.rl or oflcftrl lir ek ll ho$c\tr. rh. t{ildinB oi nrymvcnEnr h $ld wirhin otrc ,ur <br />oicotrplcrion. rne Owmr Buildc! will haE rhc hudcn oi rmviry rhlr hc or +c dil nol l,uih or nllprcn rh. pmlleny ror tr. purtby or <br />Lato* crofrhclln)n.ny. rcrclurivclrc.ntkringtrirhli.cn\cdcotrrxctmn,conntudrh.pn)jd(S..7(}]-1.8uinct\ <br />aRl Pnli\\i.n G)dc: Thc C.nrd.rtr \ t-i.ctr\c I-r* doc\ nor rrply b rtr otr tur nl rn,l]tn y sh. tuild \ or impnEs r lkrcon. <br />id who 6itaci\f(tr\uchpmjcrr\qirhrCotrtrckn(rlic.tr\cdnur\urrk,ihcCont&ttr1Li.ci{.lrta) <br />I r crcnrpt und$ Skr o I ,{ l't' lnrr[n .r!ri <br />Drre orner: <br />woxxr rc' col*r rli,r'irol <br />D[!:!IAArI0! <br />I hEb, arimhdcr pcnrlryofFrjuryone olrhc lollowin8 dcclorrrions: <br />thrrcanJwill'nsi'nrinrCcnifiurcolConsrnri'Scltlnsurcnn*orkcK.ompttr\rri'nr,r\pnrnhdturbySc.rion.lrrx)olrhc <br />Lhtr('{xlc.i(trrhcp.rronru ccolrtuwor\lar*hichrhcpcnni isi$ued <br />_lh.icnod willmoi.lain workcB .on[.n. i.n insurdncc..s rcquircd hySNlio.]7(x)oflhe tjhnr Codc- for rhc pcrtortuncc.f <br />the sork lor wnich rhis t'cmir is i$ucd. Mysorkd( snp.nsdion insuntrmqdicr 0fl1B'licy nunrbcr lrc <br />Icrnlyrhrrinrhctcrfonmmfolrhc*orkf(tr*hichrhi\|xrnirisi\\kd.I\hllnor.n[k)tanvr^--*o i']nfynr nE <br />$ r\lo hcconr \rhlc.lro lhc uorkcrs compcn{trnr h$sof('rlifi nr. rtrd rtr.c rhdr ill slDuld 6(con. {,njcd hrlr <br />workcr ..nDcnsiriontmrisiotrsolSccrionlT(x)olrhcLfitr(-onc,lshtrll I conDly wirh rhE pornioDs <br />WARNINC failurc n' trurc s(trkcs comr.nsrinD covcrasc is utrl,r rnd shxll n'hllcr rtr cn+k)kr r. cnnn il l{mlrir\ nid <br />(illl linrs ur b o ! htrnd'cd {housrn{l dolli.\ rll(x).lXx)). i', x,ltlir rd ol conrpcn\drnn,, da rrgcs .( l)n)ridcd hr rhc <br />scc!on ro?a orhc 1xhtr(ndr. i, .rf{ rnlxiinn.y \ rccr <br />I hcrcbylnnNundcrlcmlrroipcrjuryrhat I rD liccn$!u crpmvhionoiChmrcr9(conlcncin8sirhse.ii,n7(xr0)olDivi\b..1 <br />ol ihc Bnqnc$and PmfcsiorsCodc. aM nylicctr{ is in fullf .c d cliccr <br />IjA!$BIICUANIEIDINIiAGEM;I <br />I hcrcby 0flirf,und.r Fh,hyorp.rjury lhal th.rc i\ r.onsrfl.lirn hndine qcncy for $c pcrlrirNncc olth. work fin *hichrhh pcrmir n <br />issu.d (Sc. 1097, Civ C ) <br />AITIIIAITLDECIAXAUA! <br />I hc.ct y uninn undcr lrnrhy olpcrjury o"c oirhc Lllowins dcchnlions <br />D.mlirion Pcrmils.Ashc(os Norificrrion ljcderalltc8ulariotrs llirlc40- PlrrO <br />-Rcquncd <br />Lellcr of Norifi c.rhn <br />I (.,rilyrlrrrlrc lrnchlrcguhri{,tr! rcguiir! r\l).i.:run$rldc ! nt,t)lniUc t) rhlr l).tc.r <br />I..nilrrtu( I hrvc rcadrhi\ rpplic!i <br />o nrncc\ r Srrrc lr'(sr.ldi',9 k, $tr' <br />rbok nrnri,nEl piopcnl lnr in\rh-(ion <br />inin'ruri(r i\.omcr I JgG b.rmply *irh all <br />hcrcby arrhtrizc rcrcscrr,rivc( olrhii Citt !nd <br />Anpli(nnl or AEut SiInnl(rc <br />I <br />I <br />t-+-