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BUILDING- INSPECTOR HECORD
<br />DATE ID/SIG.COMMF}ITS OWNI]R BUILDER DELC,\NATION
<br />I h.(hy afilrd undcr p.nrlry oI p.rjury rhsi l arn crc,nl,l lmnr rhc aln racron l,icensc l,N ru rh. rolbwine.c,bn (Scc.7031.5
<br />ausincs r Profc$iofl Codc): Any Cil, or Counly phich rcquirc\ ! I.mir b L\,n\rtu.r, .r, inprcvc, dcnxnirh or EI n any
<br />srrucru.c, prior ro irs hsuke. dso rcqlies rhc applica tu \!ch l*mrir k, filc i \iSnctl smcnrnr rhar hc or shc h liccnscd pursi
<br />ru rhc pn,vi\io.s ol rlf, Conrrcrols Ln nsLt t-rw (chrpr.r 9, Comnkncnrs wirt Sccrion ?(x)0.f Division I ofrhc Busincs trtrd
<br />Pmt$nns Codc)or llrt tEorshc hcxcnrpt lhcr.hflotrd lhc husi\ lorrhclllcscd crc Uiotr. tryviol.rionoiScclion70.11.5hyatry
<br />rpplico tu a rcrmil subjals rhc aprlica ro ! cilil pcnllry of R nrr. rhan fiv. hundtd dollaN ($500).
<br />l. rs oBncr ol rhc lml)cn y. or my cmployccs wirh wa8cs !s rhcn y,h conrFnsrr ion. siU do lhc *o* lrxl rhc {tursc is R
<br />inrefrk{l .rolTcrcd fu slc IS(.7O1-{. Busincss d Pft,r.ssnnN Cd. Tlrc Conka.rois Lkcnsc hw docs tror sPply h 3n owncr oa
<br />rhc pn,rny who huild\ or i,np()ws rhcRul. l who d({s such $rt himlclfo, icr*lfor rhmu[h hi or hcr o$tr cDlpLyc$.
<br />!'ovidcd Ih0r \u.h imnorcnrntsm mr i c&lcd oroterci lhr {le lf. ho*c\rr, rh. huiunrs or irinmvc.* kvnd*ilhrnorcrar
<br />oiconpbtion.lhc (a!rcr Buiklcr eillhan lhc hor&n of pn*ins rhd rt oi sht did tr.r huild or nryort thc |n,lE1y lor llE nurF'$of
<br />l. r\owncrolrhc pmprny. rncr.lu\iv.ly..ftr.rir! wIh li.cr\c c.orri.rnsrorotr{tu.rrlt pn))c.r (Scc. ?(!-1.I]usm$
<br />rtrd }lllir\irrCodc Thc Conrra.ktr s Liccn\r l,aw.loc\ rorrpnlyt' rio*Rrof|to]r fshohnil&orirnlrovcsrhcrcon.
<br />trnd *lD .o ruck lnr \Lch fn,r..( sirhrConkr.n,(n li.rnscd ttrr{hnr k,rhc(t rlcloi\ l,iccnsc lr*)
<br />I rD,dr.n,pr unJrr S(rn,a8. z- t€
<br />DI:gI,ABAIION
<br />I hcrch, rfiirm trndcr pcn,hy of ta.^rjrry oic ofrh. n)l[)sing dL{ldrri(!]s:
<br />-lhrvcaodwillnEinrainaCcnifi.ur.ofCoosnrbs.llln\urcttruorkciscomDc.sarion.a\IDvid.dlorhrs..rionl7(xlofrhcLnbor Codc, for rhc pcrli,lmae oflhc soi( nn stich rhc permir i\ is\!c{
<br />rhr {o lor shich rhisp.rnir is nsed Mveortcn .onlf,nr.rnfl ir]nnrNc.uricrnn Frli.ynun$cr r.
<br />I ccnrryrh.r ir lhc |x ronn,trcc ol rhc trort lor nhichrhh pcnnir
<br />$ $ ro hcotrE ruhjccr ro thc ro.hs( coolr.nilli.i h*\.fCrlifttrhl
<br />sorkcrs co.f.n\!rion prori\ionsotSccrion l?fl1 of rhc Ltrh, Gxlc.
<br />ttAR\!N(; I.J lu'. h' qu'. w'{k$ ,,anFn.rrn{r ( !flJ8c h u
<br />cilil &rc\ xf ro ond hundRl rhous!.d dollnr ($100.000). ir lddir
<br />S{r n,n :1076 of rhc trtn Codc. iorcrci rtrd orrrrcyi iLrs.
<br />is is\!cd.l shru nor cmtk,yr ylEnotr in rny manmr
<br />ia, and,!rcc rhd ifl shuld hec,'m suhjccr iorht
<br />I shrll. tonhwirhcomfly'ilhihoscpmvti,,n\
<br />tr]trwlul. nnd xhau {rhjc.r ,n.nDlorrr ro oiminrl pcMiics ond
<br />i, ro rh. N{ .l.o rtD
<br />e-e.18
<br />DECIJEAIIaN
<br />t hcshy aftrmundr pcnrlty ol pcrjury rhot I aD liccn$d undcr pmvi\ion orChq,rcr 9(.oinmncir8 wilh Scclhn r(xx)) olDilhion ]
<br />or rh. auiinc$ and PmLssbns Codc. arn my liccnsc h in tull forcc and cffNr
<br />IONiIAIJSIIANII,NDTNC.{CENI:I
<br />I h.ehy ifitn undcr pcnrlty of perjury lhal lhcrc hu.on(ruclion knd g iscn.y lor rhc t'lylonmncc ollhc $ork n, *hich On t'!ro[ n
<br />issucd (Sc. lli97.Crv. C ).
<br />L'lh,. \
<br />'{'c
<br />AfIUCAXLDECLAf,A.ITIJ!
<br />I rmt't.nnnr undcr |Enak, of lErjury onc ol lhc lhlloNin8 d(larurions:
<br />Dcnnliri{,n Pcrdi( A$$tx Noril,.dn,n tud.flIR.guhrions arirh 40. Pin6)
<br />-Rcquircd
<br />lxrrcr ol l{difi .man
<br />I.difyrhd rhc rcdcril rcSuktirns r8udin8 asbcslosrcnn'ql rc nol aptlicahL ro rhk pn,jd.
<br />-l
<br />ccnilyrhar Iha\c rc rhirrlllicarionaldn,rcrharrhcrh)rcinknkri(,ni(.or$t.I.Eelocomtlywirhallciryrrdcoutrry
<br />.rdnErc$rnn Sr c L!'s slaring h boilding cointudi,)n. Md hcr.braut,xriTc rcprcrcnrarives ofrht Ciryand c()!nr, to cnrs uP.fl lhc
<br />ih.!. nrn,..rc,lrn|{nr ro, ,n.Dc.rion nulrixql ;-'-
<br />Apprnm,.r^Aen,srm,ure X c{"", /4 ,"," 6" 3- iP
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />Subf loor/VenVlnsu lation
<br />Rool Sheathinq
<br />Framino
<br />lnsulation/Energy
<br />Drywall
<br />Brown Coat
<br />lt/laso n ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />I
<br />FINAL -z//r/4 -4471,
<br />Certilicate ol Occupancy
<br />Notes, Remarks, Elc.
<br />SITE-WORK
<br />SLAB Floor
<br />Shear Wall
<br />Ext./lnt. Lath
<br />Flood Zone Certil.
<br />Poli.y Nunh.r:-Expirci
<br />-
<br />Lic.nsc Class
<br />--Li.eB.
<br />Nunb.r:
<br />-
<br />Drl.r Conltulo.
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