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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE?'Jq/SIG.COMMENTS OIINTJR IIU I LDER DF:I,(AIIATI0N
<br />I hcrchy rffrm utrdc! Ntrrlry oi lcrjury lhul I anr crcnrpr ltin lhe Conhrro^ Li.ctrsc Law litr rhc foll{,sing r.l {Scc70ll5
<br />Busircs lnd P(nisioo Codx): any Ciry or counry whkh rcquncs r F_rtrrir ro cn${rucr- !lir. nnProvc. dcnxnnh nr rcFrn rn)
<br />{d.rurc, trintu irs is\urn-c.oho rcqurcs thc lprlrcmr tu such Fnnir r, fihr \i!trcd sarcrrc lhilhcor shc is li..nscd lxr\xmr
<br />ro rhc ,rovisnnrs o, the A,nrrlcl0 c l-ic. rd lrw (Chrpr.r 9, C..nncn.irg wirh S.crion ?On or Divnn,n :l ofrhc Busi c$ dnd
<br />Pdi\\i{,trs Codc)orrhlr lDorshd iscx. rr rhcrrronrnJ rhc h,sk r'or llt rllcscd cxcnrflt]( AnyvnnnriotrolscclionT(r:ll5hy!rt
<br />rr,fli.n rar r l.rrnir suhjc.B rh. iptlicanr lo rcivilpcnrlryoinor nnmrtun fivc hutrdrcddollaF($5(I))
<br />L r\ owmr of rlf, F)If,ny. or nry cnrlloycc\ wilh wasr! rs lhcir $lc . nrp.n\ari(nr, will do rh. Eoll onl llE (nnuB i\ ior
<br />iNcDdcn oroftrcrl tur slc (Scs 7tr4.1. Eusimrs md Prolc$ion\ Codc Ihc Crontrcl.is l-iccnsc l,aw docs nor arlly ro an owNr ol
<br />rhcp,txdy *lr, tnriu\ .r i'n|,.[s rhcto$tr. n whodocssu.hworthi'n\cliorhcr\cllorIhnJulhhiso.hcroan.trPk,)t.s
<br />ln,vidcd rhor su.h impmvcnrnB m nor inrcnlcd or oficRd ntr slc. ll ln'q$!r. rhc buillirg or ir{,nt 'kni i] sU wihin .nc Frr
<br />of.onlPkrion. rh: Osftr BuiklLr will turc thc bunjcn ol [ovin! rhalhcor dr did ton hoiu r in{'rov.lhc IoIEny fi, rh. luqr,{ of
<br />l. nsoandorrl[ prcpcny, aNcrclusilclyconlriclirs silh liccnrd corLa.roN l..onnrucr rh. tmjccr (Ss. 7044, 8u{ncss
<br />arkl PnltssionCodc: lhcCo rackx s Liccn\c I-n*do$ tror rtrlyro itrorncr ofproFnysh(, huilds.r imprcu{ rhcrcon.
<br />and tho .r,nra.kr.,\u.hf,jdsrth0C..rrrctonrliccnsdnlFunrrurh.c.trkrdoisLicctrsL!w)
<br />I d cxcnrni u cr Sc.r 0 ,t l'C lnrrhtr' \rl
<br />Drl. Owner:
<br />ll()Rtn is contplf NsATx)N
<br />IESdAAIIAN
<br />I hcEby affirn utrd$ pcDrltyofNrjuryonc olthc rbllowir3 dcchdnn,s
<br />lhrvc md w,llnui ainoCcniaEarcoiG'nrnrroS.lllnrurcfitrsotkcrfconrrcnsulion-as pr,!id.drorbySccrnr:l7U)ol'lhc
<br />titrtr Cdd.. r.r rhc ,)clformNc of rhc *o rbr which rhc pcrmir is is\oed
<br />dzihrvcrndtrrllnuinhi'rs.rll^'rirmpcn\Jri,{''n\utur.c.n\rcqutdbySccrn,n:l?(x)orrbcl.trhorCodc.lorrhctcriorronccoi
<br />lhc wolk lorwhi.htht pcrnir i* Gs'.d Mywor*c6 co ll{nsarion insunncc clric. lnd Policy.umb.r m:
<br />V.L c)
<br />-l
<br />ccnifyrhxr in rhct rrortuk.of rh. sork rDr (hich(his pcnnt is irsud.l shrll nor rnPli,yr0yn non lnynutrncr
<br />lrrte: t g 7iry::L/'
<br />Lll-llsu2-loNl]t ula
<br />I hcrchy al6fl.under petulryofpdjort rhar I a li.cnkrl undcr fmvkion ol Cha/s 9 lsnntming wirh Sccl i.n
<br />.f rh. Rnsi',.\rstrd Profc\\i'rnsC.dc. md mv li.cnsc is in tullforer clltcr
<br />4.L.1-
<br />coNslRt:ct tor I ti\DtN(; a(;I.i\(t
<br />I hcrc5y 0lfinn lndo rnah, o, ,erj!ry rhd rh.r. it a .onqrtu rion lc.dirB !tscrc, lnr lhc pcrrormkt oi rhc work for whi.h rhn Fcmir is
<br />irsucd (Sc.. 3097, Civ. C.l
<br />AIBI.LCANLDECIAMIIQN
<br />I lrn{'y Jitr undcr penalry oapdjxryonc.rrhc f.llowinS dcclararions:
<br />D.nmlirion PcrmirlAstEsros Norificarion Fcd.ml Rcgxlnrion! (Tirl.40. f0n6)
<br />-Rcquncd
<br />Lcrter otNolificari,n
<br />I.cdiry rh,r rhr rcdcEl rcauLrions assdinB Nb.nor r.niJval m mr i0rlicoblc ro rhis poiccr
<br />fuinlrv,u rr.,'" *,a,r,s snpl'Lartrn.rkl { c,h rc 0t$vc n,ronnrr ion is comr. I +rd ro.on,Fly vith rll c,ry lid (rouiry
<br />Vrdirun(c\ anLl Srorc lj{r ruhin! r. hu'ld'n8.on{ruirhn. .nd hcrcby !urk,i/c rcFctnrariv.s (,rlhil Ciryand Coonly r{, cir.r uFD rhc
<br />ih.n.nFnr'.n.J Dnimnv Lr in(ffirion Dumscs
<br />orr*,, * no-, .n-** * --Z-z tt(- ,",. (
<br />U"-,U""no-",0rn,,' Y
<br />s/3#
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsu lation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL
<br />Certif icate ol Occupancy
<br />Notes, Remarks, Etc
<br />-+
<br />\) r{b h...o r \uhEcr ro rlrc wllkss conrrr n\arion h*s olCrlinnnir..M r8rc hd ill should bcn,nr subjc.r h rhc
<br />sorkcrl confctrsoliotrp&ri\n,nsofSc.ri{,nl?(ruofihc,nhtr(i c.I shrll, Ionh$irh o!Pl} wlrhrh{)* Pmvisil[\'
<br />WARNING ,:rilrc t, krr sorkcrj...rlE s.rion.ovcmgc is unllrful- rnd \hrll nrbjdt r cnDloltr lo criNin If, xlric\ ri
<br />civil ft(\ up k' om hundr&l rhouend dollnr (Slu).fi)o). ir oddiln,n h rhc.o{ uf.onD.nsllion. dlnugc\ !\ PnJridcd n, rhc
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