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BUILDING. INSPECTOR HECORD
<br />SITE-WORK DATE ID/SIG.OWNER BTIILDER Df, LCARNTfi )N
<br />I hcrch, aifirm lndcr rcnally o, p.rjury rh lnmcxcnpr fiom rh. Co r.clom Liccnsc Lia tor lhc iolk,BiflE rcrsn (SccTOll J
<br />Bu\in$r nd Prolcsioi Codc) An, Ciry or Connry which !.quircs r Fnnir lo conndct. rllcr. im!rov., dcmlhh'!r rcFn my
<br />ll,!.ruB. prntrro 'rs n\uutr.c.,ko rcquncr rhc afplicant for ch pcmirto nE a shred stitcnEnt rhar hcor shc h liccnsd plruinr
<br />r. rh. F'vi\i(,ns oi rhc Conlnctols Liccnscd Llw lchofrfi 9. Co'nm.n.in8 wirh S..rtr. 70ff) or Divisnrn I or lhc surincss aqd
<br />PmlcssbnsC.dc).rrhar hr orrhc i\.xcmpr rhc.ctomnnd thc bast ntr rh. rllcs.d cxcm ion AnyviolarionofSccrirn?o.1l56yany
<br />npplicanlr'o.. I)c mir nr$rcch(hc rrplicrnr h a.ivilp.nalry.lror mrrh3tr lir. huMrcdd.ll,r (S5u)r
<br />l..soe.crorrh.pnrltny.oin'y.mrloyc.\wirhwlscsarlh.i,hlc.ompcnqrion.Nilldorncuo udthcstdt@i\nor
<br />n crH or ofcrcd tu * c (Sa.?044. Busimrs and Pn'rd$bos Gdc: Thc G)ntncror'( l-iccnsc Law docs nor lPply o rn .un.r or
<br />thc IrIt d, wh, hilds or imprnrs lhcmn- a shodocs{.hsorkhims.lforhcrscllorlhou8hhh.rhcrotrn.nrbyccs.
<br />providcd rhlr su.h impn,v!,mn* 0rc R, imcrxhtl or ofiircd ror srh ll hoscw. rllc $uiuinS or irn0oumnr h $kl wirhn, nrc ).r
<br />ofconlhriir! lhc O*ncr Bxild.r sillhnvc (lr hxnknofpmvin8 liar hc.. shc dil mr ldld or inIrerc rhc pmplny tor th.Irurl-s of
<br />_l- sosncrolrhcflo!.ny.!rcxclusivcly.orur.rilgsirhlic.d\.d..rka.l(tr\kr.o,intu.Uh.rojcd(sc.7044.Busir'c$
<br />rnd B.r.rsi,r Cod.: l hc Conrrucrois l-iccnsc Law docs flol rpfly r) rn owtrcr oll](,|Erly sho builds or nnpmvc\ lhcrcon.
<br />rDd who cotrr&h rar such lnolcch qnh iC.nrxcrn(r)lic.'Ned nuNrnr hrhcCo ra.rois l,iccn* lnw)
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<br />amcxcmlr undcr Sccrion
<br />roatr[B[:lout[gltrl]!DIEI,I3flP!
<br />I h..chy rllinrundcr pcnallyolp(rjuryoN ollhc r(nbwi.! du.lrrrt,n\:
<br />I hrvcufrl sillnuirknr{ Ccniljc colCon\rtrrtu Sclf.lDsrrc ntrN.*crs. rotr1tr,tr{dnr. i\ provid.d nrbySc...tr:t7U)ulrh.
<br />kb.r (idc. lor thc lrrli)nnMcc ol th. w.rk f whi.h rh. pcirnir i\ i\\rcd.
<br />I havc rnd willmriniah workcri corpcnsarn,n insurnNc. rs r.\tntedhyScction.lTO(,oirhct hor Codc.ln thc pcnnrn rcol'
<br />rhc work for whth rhi\ pcrn r is h\u.rl MyworkcF conrFn\.rion insurrnccca cr:nd Fnicy numhcr arc
<br />9atts7\7
<br />_l.cnilyrhd inrhc Nrfonrr..c of rlf, trork ld \hirhrhn |xirnn is irsurl.I \hilLDor.ndoyrn!Ir^oi i'r ri! rrtrncr
<br />s, rsh b..o,m uhj(i i.rhc $orkcriconr.n{dion h*s .f Cniilaarir. an rercc rhrrill sh.uld hccotrf, suhjc.r l,)rhc
<br />sort.r\.annprnuiiorpmvisionsolS.cri{n,l7oO.illElrhtr(\idc.l\hall.nrnh\eilhcotrrnltwilhrhxcpr.vi\ions
<br />IV,{RNING' Frilxr t, \rcutu *ork.r( .ompcn\rrid, covcrrg. is u.hslul. rnd \hrll \rhj$i tro c'npk,ycr k, niminrl n nrlri.\ JnJ
<br />t, o c hr drL{l rhousrn,l Jolhrs lsl(x).(Xn)). ir rd.liri, n) rh. .o{ of.r nlPcn\ain)n- drnrg.\ r\ fntridcd lar rh.
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<br />DEIIAIAIIQN
<br />I h.rby arfirhlndcr pcndhyotFrjlry rnal I ur lien\.{ undcr,'bvision ofCnrpt.r 9 (om,rcncia8 Iilh Sccrhn ?OO0rofDilnio.l
<br />oI rhc Busincss ond Pmfcssio.s Codc- sxl nry lkcn{ s in tull rd( rnd cfiNr.
<br />B 1Z(c
<br />Dsr. L {u KGC
<br />IONEIf,U!:IIr!IDN!I!!j.&CEX.qI
<br />I hcrcby nlfirD u.,ls lrtrrltyolFrjurylhar lhcrc h a.on{d.ri(,. Lndin8 agcn.y ror rh. Firormdn.. orrh. work n, whih lhh !.flnir is
<br />i\sucd (sa .109?. civ c ).
<br />AItUCANI-llEcLIMlIa!
<br />I hctrl'y.ltim undr Fnrlry ultcrjury.nc of rhc lnlkNin! d(Lrurionr:
<br />D.nn irn P$mnl Ash. o\ Norific ion rcdcral R.aulntions l1irlc,l0. Pan6r
<br />Rcquircd tatr& of Norilidri,rr
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<br />ccnilyrharthc fcdcml rcSulariofls E8ard,n8 ashc{osrem,valm nor{Fplic,bk ro rhis pmirl.
<br />,!l c.dir, rhd I htrlc Ed rhir,mlicaiion dn rarc rhar rhe *ovc i.formrjon tcorer. I asG ro.omply wirh all Cirydnd Colnr,
<br />odi.,mc< md sr,rc tjwc rcl,r'ng ro h ildrnF.'in{turrii,n.aidhcrchyuurhoriarcrtrcE.rlrivcrotrhisCnyoddCounryro.nrcruponrhc
<br />,rovc m iotrJ llnil(n, rni iy6dionnuryi.{\
<br />- I,rpprr""nro"es-,sls-r,r/ D.,..tpdff
<br />,.-u* **,,n",pfKnaltrly Vqkn atda
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Sublloor/Vent/l nsulation
<br />Roof Sheathi ng
<br />Shear Wall
<br />Frami ng L1/L,t/&>t\q-,,
<br />lnsu lat ion/E n erg y t
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />IMasonr Y
<br />Pool Fence
<br />T-Bar
<br />Handica Req.
<br />De UI Final R ort
<br />En gineer Final Report
<br />Flood Zone Certif
<br />FINAL (i/z-1-(/3 5,-\tq
<br />Certilicate of Occu pancy
<br />Notes Remarks EtC
<br />COMMENTS
<br />Set Backs
<br />UFER Ground
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