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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.OWNEN AUTLDER DELCARATTON
<br />I hctby rmrr und.r Fcnalry or Frjur! rhd I d .kcnpr fhn rh. Conta.b^ Li.cn{ uw ror 'h. &Uoqin8 rc.qn (SN 701 1 .5
<br />Busincss and Prolcssion Codc): Any Cily or County phtrh rcrtuncs ! pcrmir ro cotrslrucr- alrcr. iniprolc. dcm.lhh or rcNn trny
<br />slructurc, lit,I Io irs i$uamc, also rcquiEs rhc applicant for slch Fnnit tu fiL a cisncd sar.mnr rhar h. or shc n lie.scd lurflmt
<br />to
<br />'hc fmvisions or rlE Cont,crors Liccn$d bw (Chapr.! 9. conmcRi.E wiln Sccrion 7()0O ot Divhion I ofrh. Bu\in ss rd
<br />P,ofcsionsCodc)orrhartrorshehsxemprrhercrionrndrhch.sisr'orrhcallcscdciemfliotr.Anyviol,krnorsc.lionT0ll5byant
<br />,pplicanr tunp.mn srbj..rs rh. aprlicrnrba.ivilrcnllryolnolnor.rhrnfilthu.drcddollrs($50(r)
<br />-1,
<br />os ouncr ol rhc pmpeny. or my cmploy.cs wirh wl8cs as rhcn sb conrpcn\al bn- sill do rtr wrk trxi th. strtm t nol
<br />i'Icd.rl orofturcdfitrslc(sr.T0,l4.BusincsrnJProfcssk,nsCodcThcconrr.r.r'sLkctrstjwdocsnotopdyrornowocroa
<br />rhc pnpcny *ho buildsor itrpms ltr@n. aod wno n.cs sch Bo.k himsclfor hcrrcllor rhrcush his ornfi own.,nployccs,
<br />providcd rhd such inpturmnts @ ft in(cd.d .! ofiE d for {lc la h,w.hi rtE bui[in8 or nrrnrtmnt k $ld sirhin onc )f,r
<br />of.orll)Lrir.. rtr Own$ Buibs will lrw rlf, holdcn of tmvi g tlu h. or \hc did nor build or nnpmrc thc lnlr*y for rhc purl)a$ oi
<br />I.asostrcrofrhrpm,rny.ancxclxsivclyc.ftdciinswirhli.cn{cdcotrmcrorrocnn(ru.irhcnroF-rlscc?014.Bunnc\\
<br />ud l-r.lissbn Codc lhcConrra.rofsl-iccn\cl,asdo.snorupplyr. os,ncr ol pi{)!. rshu huildsor nnpiovcs lhcreotr.
<br />nM who .onrB.r1f(, su.h pruF.ts wirha ConrndrG) li.ctrscd tursurnr rorhc Ci)nrndois Liccnsc ln$)
<br />I rmcxc rJ, ! .r Sc(!o
<br />]rcf,KEBS:CAUIINSAIIAN
<br />I]ECLIAAIPB
<br />I hcrcby dfttrundct pctroltyofpcduryonc otlhc followin8 dNhmlion\:
<br />-lhavcdxlwillmiinrsinnCcnificrrcolConstrrbSclalnsurclorsorkcFompcnsrion.0spn,eid.di(rbysdrionl7fi)olrhcbbd o)d.,ld ih. l.riormn.c of thc wo& torwhichrhc tf,y.rir is issu.d.
<br />I h,rc dnd will fr,ior,h worlcrs compcnsatiotr nsurincc. as Lrtuncd b, S(r ion ]?u) of lhc Lnb.r Cod.. rd rhc pc omurcc of
<br />h\ m,'n \ *rJ M\ tro,ldr c-n,mn.d 6n ,n.u, rmc lrn n rnJ R'liL! numb.'R€u t€rz *repcv -T c
<br />.l
<br />l.cnifyrhar i'r rhcr.rr.nMm.ofthc work f.i shi.hrlris Ix rnri! is issucd.l shallnor cm!loy
<br />s 0s Io lrcooE subJc.r ro rhc workcr' oDpenerion loss of C(lit'orni!. lod lsrcc rhd il I shorld be.om subj..r ro lhe
<br />workcm'comocns.rionpmlisionsofScclion]T00orthctifiorCodc-lshall,ronhwirh.u'nplywnhrho{pn)vnion\.
<br />WARNINC Frilu'c ro *curc *{trk ri.o'n .hsarion.ov.ag. il unhwful. a.d shrll suiFr an cmplorlr ro.rnninal lf,rulrar rnd
<br />-4*
<br />DIr(l,l.8:IlIl.)I
<br />I hcrchyafli'rnundcr p.nrlryofJrrjurtrh t r r liri$d uiddr t)tu!hn r of Ch.trq 9 (connmrc irg uilh Sccrion 7O1X))ofDivisbn l
<br />oi rhc llusincs (nd ProlcsionsCoJc- md mr liccnsc i\ in tulllnr.cmlcrrc.r
<br />B g4
<br />,r", r IlU t-r.,.r- I 4*
<br />(t)\5 ltt tt()N I ltNl)l\(; l(;hN( \
<br />I hctohy ,rfirn xndcr Fn ryortcrrurythol rhc. hrcotrdrucrion hlldinSasc.cyforlhcpcrfo,ro..cofrhc work rorpnichrhh pcrnril n
<br />nslcd (SE 109?. Ci! C ).
<br />I ccnilyrhd Ihc lcdcml rcgultrrions EgrdinE astr slos Emlalrrc nor applk,blc b rhis pft,j.{r.
<br />rhc rbo\r inli,rndiotr iscorcct. lagre ro comply sirh rll Ciryrnd Counly! r.-r,r !rlrr I hrvc rcrd rhi\.mli.dr'.ndd$nrcrhrr
<br />rn'l srnrc I r*\ rclaifN k, bui &*l hcmby aurhoriu. rcrc*nralivcs oflhis Ciry lnd Counryt, cnld ulhn rhc
<br />rhrd nf,trri,re! |nondiy lnr i'nnccri,n,o--- DS"Va.-xr. . o4-dc- t?rppri.-r..,r,1., Si[,.r,." X
<br />c-
<br />, ta-6s:ar€N
<br />Set Backs 1i .,..\'lA')
<br />Erection Pads I \af \\\--l
<br />UFER Ground -\ a.
<br />SLAB Floor
<br />Subf loor/VenUlnsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />lVlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Reporl
<br />Enqineer Final Report
<br />Flood Zone Certil.
<br />FINAL
<br />Certificate ol Occupancy
<br />Notes, Remarks , Etc.
<br />-+
<br />COMMENTS
<br />,2
<br />AIIUCANLDECI"AAA]ION
<br />I hcmb, Dfirn lndcr pcnalry.rp.rjury urc oflhc tulbrinB dc.lardn $]
<br />Dcmoliln)n Pcrnrils Asbcslos Noiili.dion Fcdcol Rcauhi i(,n\ (rirh 40. Pan6)
<br />-Rcq!iEd
<br />lrncr of Norillmridr
<br />Forms/Steel/Holdowns
<br />Ext./lnt. Lath
<br />Brown Coat
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