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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNTJR IIUILDER OEI,CARATIoN
<br />I h.r.hy afifln uMc. Fnally oi Frjury rhd I aD cxcnu lirnn rhc Gn tucrorr l-iccnsc llw ,ar rh. rollowilrE rcavri (s..7011 5
<br />Iturmsr od Pnlcsioo Codc): Atr) Cny or Counry shich r.qtrirc\ r lErnrir ro cotrdtucr. uhcr' nnlrovc- dc x,lilh or rclair lnv
<br />slrucrurc. rirrt, irs isudrcc. rlsi rcquircs rhcrptli. trr f{tr suchtclrnillo lllc d rigncd stalcnrcnr rhnr h..r dt il liccnscd prrrmr
<br />io ihc nmvi\i{nN of rhc conrndofs l-iccnscd l-rw (ChaPrcr 9. cD nErci'rg irh sc.ri 7(x)0 of Divisi{'r I ol rh' Btrli'rc$ nnrl
<br />PrnlcssiotrsCodc).rrhrrhcor\h.i\excnPrlhcrcfton0 lhcharislorihcrLlcA.d.rcmprion AnylidrlionotSccri(rn70ll5bvM,
<br />rmlicrtrll'or a pcm,il rubrc.rs rhc q'tlicanr Io acivilIcnrlryofnor lnotc rMn fivc hrndrcd dollrs(5500)
<br />-1.
<br />r\ o*rcr ol rhc l,oFny. (n nrycnDlotccs sirh wrecs is rhcn solc cotrf.n\arbn. *illdo rtt wntk,nd rh. sruruc N 'rinrcndd oroflarc'l Ior slc (Se.' ?O.ld BusimssaNl Proli$ionsCodc:Th. Clr rrcroisLltctr\ct-r{docsnolaIPlvt)triowtrcrol
<br />rhc prclrrly who huilds or numrcs rhcN)n. lnd who dm\ \uch s.* hiDrcll or hcsulfor rhrou8[ his.r hcr owncmpbvccs.
<br />pr.lidcd rhrr srrh iNrrovcftnh d nor imcft.d n olltnd lff Mlc Il nowcvcr. rhc hildi'r8 or i'r{,tuvcmnr n $h sirhi" "N F'tr
<br />ofconlhri)n. rl.. O*trcr Buiu.r willhrec rhc budco ol |r virr8 rhar IT or \h. dil ml lDiU or i',VR,\t lnc Pm|cn, inr Ilr NrBJ$ ol
<br />1..\osNrol'rhc pop.ny. dncxclusivclyconrrncri',g *irh li.ci*d .onrrrtF t, .on{fl.r rtf, proicr (S.c 7L\4.8L\ln"\
<br />rnd rt,Ls\inr Cdlc 1hc Corlrlcrois Lic.nst Ltw d(E\ nolal)Plyt, riowtrd oftroocrry sh.l,riltls or iDlovcs rh.rcon.
<br />ond who cont cls lt- su.h l)re1..h Bilh a A,nrrockni n li.crrtd !trnurnl brlt Contn.!{ sLiccnsc l-aw).
<br />I urcxcnrpt undcr sttion-, B &PC Iorlhis.cr{,i
<br />Drl*
<br />-
<br />osner:
<br />WORKFEi.{)I'{PENSATDN
<br />IIECLAf,A[IO!
<br />I hc.cby affinn undcr penallr or Pcrjury om olthc lollowins .lcclaalionsl
<br />-l
<br />havc and will dinrnin a ccnifEarc oi CDn*nr k, sclf-lnsurc for rorkcc' ..n!tnsd ion. N lrNvided lor bvScclio! l70O orrhc
<br />bbor Codc. for lhe p.rfor@cc ofth. vort for whicn rh. pdmr i! issucd
<br />-l
<br />hsve and will 'tuin'fi worlcn' comP€n{arioi in\urumc, as rcqutud by Sc.rion 3?m of lhc L,bor Codc. for th. Ii.fi'lfunc ot
<br />rhe sort ior whi.h lhis t crmil is i$r&n My worrcn conf.nsalion insuunN cdic! ald F,licy nxib.r a.
<br />",(
<br />Sr+1E- Fu)Dg 2-<t t k
<br />I ccnrry rhir in rhc perfornr rc ()frhc work tlr rhi.h rhi\ Nnnir ir isucn. I \h ll dor cnlPlov rrrv pcr$n i'r ary Nrnncr
<br />s s to hcgrm \!l'jNt t, rhc wo cN compcn{rnr hqso{calilorni!. rnd 4Nrh.r iiI nruil tftonrc {bic.rrorhc
<br />trorkcs' conFtrsar n,n Ptuvkiotrs ol Sccrion :17(x) or I rt LrlEr Code, I shlll tudh*irh conr/v $ irh rhos !rcvhi'ns
<br />WARNING rrihrc lo wurc *orkcn .on{'ctrsilior colcrrge i\ urlrslirl. rntl \h!ll sDhlc.r trrr cnrPlovct (r (i'nirrl Pcnrhi\ and
<br />cilil llics uD ro orE hundr.d rhous nd dolltr^ (SllX)-(xxD. in rdd n t0 lhc .on ofc.nl)cnsrrion da'D!c!,s lrrrilcd lor rh'
<br />s(rion 1076olr,rc t tu C.d.. inr.rc$ and o!Ey\ lc.\
<br />"*".4
<br />DqCI.ABATA!
<br />I hcreb, alfirm uNlcr rcn,kyoflcrjury lhol I am liccn*d xnd$ pmvnion of Chll,d 9 (conrmncing wirh scction TllOO) 'rDivisi'tr I
<br />or ihc susincss and Pnfes\n,ns codc, snd my liccnsc n in flll ror.c a clltcl
<br />3ll€E
<br />u""b /8 -"*** )4tJ 4^J
<br />QNUflJSIIANTENDIIIi.trGENCI
<br />, h.rh, arfinn under [Enrlryofp.rjury rh0l rhcrc h r conrrrucrioo kMint ascmy for rhc t'.ilonEme olrhe sork i(r whi(h rhi\,'&mii h
<br />i\\ucdtsN :rrlr7,civ. c.).
<br />Lxtrdc,\ AJd'c*
<br />-
<br />APPI ICANT NF(:I ARATIoN
<br />I hcrt5y Innundcr pcnalty oirlrjuryon. orthc
<br />'blloeirr
<br />dcclarariois:
<br />DcoDlirion Pcrnik Arb.{osNolifi.*ionFcdc6l R.8uhn,ns(Tir]c.lO-Prd6r
<br />Rcquircnkrrcrol M ifi.ardr
<br />,ri,)n\ rc!!dirA.shr{osrcnr)vilrr. ior rtNrihlc l,)rhi\ p(!c.r
<br />li.dkrnnddrrrrhrr rhonhrrc rtrlornnrionncomd. l.sreroconr/tRth0llCitlr.da)rnry
<br />hcrcby aulnorir. r.ptusctrr.rivcs olrhn Ciry Md Counryro.nrcr ulon rhc
<br />h,vd trr ri(!rd oroEnyio.
<br /> pplicml or Afienr SiEnetuE:
<br />Pedn.c mmelpdn(t:E fuJ ","4r14y
<br />Set Backs 0 (>\6t
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulalion/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It/asonry I
<br />Pool Fence I nlrrr*- LZ t I q ilt&fi
<br />T-Bar 4ctt),J- .t ftu-\. '
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certil#5\_)l a\6r*{t) krttxEp. cl(-n{-,Aq 3\1.l(
<br />FINAL 7/6,10ffi /6>---
<br />Certilicate of Occupancy -l'-
<br />Notes, Remarks, Etc
<br />a bi
<br />-)1
<br />Det+y Uuor h bt Pear r.
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