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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDIR DELC RAIION
<br />t hcrcl,y afim undci Enolry of t'crjury rhrr I un cxcnUr irorn rhc Conrrmrim Liccnsc Uw for rhe'lolk,wine,.abn (scc.70315
<br />Busin.\s nod Polcsion Cd.): Any Cnt or C.unry which rcqutci r p.rn t, .onqfl.r, ,hd. in rovc. &mlhh or rcran any
<br />soclurc, lrior to irs isua.cc. rho rcquncslhc applicrnr 6r su.h p.i,nn to nh o sisncd (rtenrcnr lhal tEor shc is liccn{d PLhuair
<br />t, ihc nnli\nrns of rln Conrra.ttr\ l-iNnsed l-aw (Chaflcr 9. Co lErcing sirh S.cridn 7{x)0 of Divisn'n I of lhc Ausinc$ and
<br />Pbfcssi.ns Codc) or ihol h. or shc tcxcm/ thcr.rtun dnd rhc hnsh for thcallcScdcxcmplion Anyvi{ntrlionofS€crion 70115 byany
<br />omlicr.t for{tcrmil subjels rhc omli.a.l to rcivilpctrrll}olll()I morcthln nvc hundrcd dollan (5500)
<br />t,/N) h \ncr,,rrhcnn,ltdy.,rDycirfl,rrrr!w hwJlcs!srhLt$1...n{rtrs,tnnr.Eilldothc*orka lhcntutri{ n
<br />inrenlcd or ofcrcd for elc (Sa.7ori. Busnrs\ and ftdtsions Codq Thc Conirur,tr s Li.cns. trw do.l ..r apply ro an oqncr of
<br />rhc tmF*ny who hoild. or in orcs th.mn. rfrl stx) des such qoA hnnsclfor hcrcll or lh'ough hk or hcr o*n emrloyccs.
<br />pn,vilcd rhar \rch inprolcftn( m tur ihrcndcd oroffcrcn tuek ll ho*cw. rlf buildin8 o. inyrcvcnEtrr is sld wirhlnuru
<br />'c'rofcoryhrion. rlE O*mr Auikhr sill hivc llr burdcn olnmvir8 thot hc or sh. dil m,Dild or improt rhd pmFly ror ll* purtDcof
<br />l. Js usNr ol rhc nbtd ry. mr cx.luvvcly coftrcrinA silh li.ctrsd .onlr r!6 t, connrud ltE pr+rr ( S.. 7(11,1. Bunt$
<br />xl hUr'ssinrCodc'lhcContacnr'sl-iccns.l.rs,bcsnorrppltt,aio$ndollrot,cdr_shoburlds.rrmtovc!ihcrcon.
<br />itrd trh.oM$tusuchpmrdrl,irh0Conrrudonnltcctrsdnu ua.r ro ih. Conrrctn\ l-iccDsc Ij* )
<br />-l
<br />amcxcnrpr undcr Scclio'D9-rb -rg .",..X
<br />IESANAIIqN
<br />I hcrcb, aflnmundcr pcnahyof p.,juryo.c of ih. folk)!ins dslaration{
<br />-lhovcondqillnuinruinaCcnilEarcoiConsnltoScll.lnrurcr'orworkcBcompcnsrion.asprulidcdr{trbysalion3100ollhctibor Codc,lor lhc trrlonMmc orrhc work tu shi.h 'hc,smi k nsucd.
<br />I hrlcand will mi'nain ,or\.ri confcn\rrior in\urumc- rs rcqun d hy Scdnr :l70O ofih( tjbor Codc. Ln tfu [rcrtorroncc of
<br />rhc sork for whichrhk p.mrir is isrxcd lrry workcri dnn i\rrion nNtun.c.nricr &l!.li(ynuD$cr rc:
<br />Polic, Numbcr:-Eryircs
<br />L&41 .cn iry rhlr ir ihc p.,loi,rutrcc or rhc work ro which rh r t[ nir i! 1s$cd. I \ru rl nor gnphy , ny p.no. ,n m, mlnnc,
<br />v' Abhcdn* \ubjsr h rlE *ork.B conf.isr'in l,wsorcDlilarnir. rnd 4ncrhtrr irI.hould beo.E sub,cd rolhc
<br />sorkcrs co.ipci\rrionprovhn,nlotS(rn,n:l7l$olrhctihnCr c.lrhall, k,nhwilh co.Dly wilh lho*prcvhion\
<br />WARNINC: t'lilurc to Ecurc wortcrs ompens inn corcflre is unh*rul. and shrll suhjc.r n .ntl.)tt to riminrl pcnalrts and
<br />civil incs up to onc hundrcd rholslnd dolhr ($lllo.lt ). in lddirion h rhc c.n or.ompcnsrrn'n. dru8cs !s provided fu rhc
<br />S..riotr.ll)76 ofrhc I rhtr (_, c.inroro{n rrttrtrcy s lir\
<br />o",.. Og - l))-t( ,rppricunr, )'
<br />D!gI.AXAIIO!
<br />I hcrbt ffi.n undcr r.6rlr,oll.rjury tld I nr liccn*d undcr t,ovntun olChoprcrq (om'ncn.i'rg wirh s.crion 7m0J olDivti.n l
<br />of rhc Burinc\rdtul P6f.s*i.nsCodc. rnd nN liccnsd is inlirlltureatrdcfl(t.
<br />(1)N$TAIICUI}NIENDINJiJGEN.CI
<br />I hcnby ufltnundci ltnahy ol r.rjury rhd lhcrc is acDNd.rion lcndir8 Ucncy r'or lhc pcnnrnufrc orrhc sork ror {hich thh Filnn k
<br />i\sucd (Scc :109r- Civ C )
<br />dttllcAllDlil;Li$AlllrN
<br />I tErchtnninnu cr p.nallyof pcrju.yoncof lhc nrbwin8 dal [lions
<br />Dciolirioi Pcrnia A{bcnor Nori0.dn r fadcral R.guhrnrs (Tnh 40, P.fi6)
<br />Rcqrirdla .rof Norifiulion
<br />I ccnilrrhlrrhcfcdcralr.strldrions dBddiig !sb.nos rc x,vuldrc Nr r!plicuhl. ro lhn rojccl
<br />lArl..niry rhd I havcrldrhifuppli.arionotsr0rcihar rhc alsvc nrioxr(ion is.orccr ls[Erb.onrtlyw h rll Ciry rnd Coutrl]
<br />.id'n,m.s dnd sr d tiws Elari:e ro bxitnrBconstrucrion..nd hcrchy lurhortc rcprc\cnrurivcs orrht Cirynnd Counry rD cntcr upon rhe
<br />!6o!c nEnlioncd pr.pcny i.. inTccri.n -ti'
<br />ApIliLotrr o. ABetrt Sianlrurc x *,",O9'h:\{
<br />Set Backs
<br />Forms/Steel/Holdowns i^7 -\r\B/^\
<br />UFER Ground /\oP \.^[N/
<br />SLAB Floor /.N'A'\
<br />Subf loor/Vent/l nsu lation
<br />Roof Sheathing -.. a\(J ,rt)
<br />Shear Wall /-\'\'-ln*Xd'
<br />Framing 7 \"'t'y
<br />lnsulation/Enerqy &7b7 /N 'r J/71
<br />Drywall gpl,w 'rN v,
<br />Ext./lnt. Lath ,978/ iP. 'rlly\
<br />Brown Coat lf-.rakL,4l*l R G*r./9/,
<br />+ksofrry rstlicl,.t c'-ll"lk tt*!lhc)
<br />Pool Fence
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil.
<br />FINAL I 4lt1l t* 1i b)
<br />certilicate ol occupincy TI I
<br />Notes, Bemarks, Etc
<br />i-)
<br />Erection Pads
<br />T-Bar
<br />Liccns. Cl,ss
<br />-l,icensc
<br />Nlmbcr:
<br />l)6(€: Codndor:
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