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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILlIER TIEI,CARAT'ION
<br />I h.rcby il6nn rndcr Fnahy of Frjury rhd I un cichpr lmnr rh. (inr.lctri l-iccik Llw f.r ih. f.ll.wng rds (Scc.7o.ll5
<br />trusincss {.d ProLsion Codc)r A.y Cny or Counrt which mqrn.s , pcnni o .onslru.l, ,llcr. improvc. demolhh or rcnrn ony
<br />struclurc. t orlo ns issuarcc- oho rcquncs thc optlicMi for su.h F mi Io lilc r si8rcd slalcmnl thlt h€or shc is lianrcd pu.suanr ,
<br />k, rhc lftvhiont orrh. Conractor's Liccn$d tf,w (chnprer L Conm.ftinS wirh S..rion Tom o{ Divisidr 3 ofrhc Businc$ onJ
<br />Pml.sionr Codc) or thal tu or slE is excmpl rh.rciromu lhcbusniorlhcollc3cdcxcnprion.Anyviol.rionolserionToal5hyrny
<br />{tlicanr for a prrn: cur,jek rbc drpliGnr tu d civil pcoalr, of nor 'mrc rMn fi!. hunddl d.lltus lS50O).
<br />l. is ovncrof(hc pbFny. or my cnrrlorcs *ilh s.!.s,! rh.n $h conFns.rion, will do rwoltandlhcnulN is mr
<br />inrcB.tn or oficrcd lor slc (Sa.70.U. lrusircs rnd Profcsions Cftic: l hc Conhdols Liccnsc L3w docs ool arpl, ro m owrcr or
<br />rhc F)r.ny wh. briHs d imptuEs rhtdn. dd qb dcs soch rork hinsdror h.rs.ltoi rhou$ his.r h.r owncmployccs.
<br />povidcd rhrr such impmrmnk m ton intnbl or ollarei litr $b li ho$(r.ln. tuikling or inpmk!ftnt Ls $k wnhilr on! Jrd
<br />ot o.llllclhn. thc Owncr Buiuq will h(rc Ihc ttrdcn ol I'$vir8 lh.r h. or shc di.1 mt tlild or in{or lh. rreFr, t, rrf, purFl{ or
<br />l.r\osmrollhepr)pdy.merciu\irclyconta.ri'rgsilhli.cn\.dcotrtrcttr\k,con{turrrh.!n,j.cr(Sc.70,lJ,Bu{trc\l
<br />rDd Pnnar\in Codcr'lh. Cotrrr..ra s Li.ctr* Lnv do.r iorxtDlyk) dtrotrrcr.l nn,nc ywho huilds or nnnn)vcs rhcr.on.
<br />rn *ho contrc(ftn \u.h t,.Jcrr\ wirhrco trrr{i\) li.c,Nd pursurtrr t,(lrcco er.ntr's Li.ctr{ tr$)
<br />-l
<br />u'ncrcnrpl undqSccrio.-.B.&P.C. lorlhiieo$n
<br />Drt. o*n..
<br />ultBtr[Be.l;! trlNraftgN
<br />DliCIrlS IjQN
<br />I hcrch,r,finutrdcrlcuhyofpcrjuryon olrhcnnb*i',8dcclarrrn,n\:
<br />-l
<br />h0vc and willnuinllina Ccrl ilrcarc of Consnt ro Scll-lnsurcforsorlqicotrlpcn\ari.n-,s pdviddd roi hyssrDn:1?(x)orrhr
<br />L{bor Codc. lor lhc t rfmmmc oflhe work lor whah lhc r.mil is issucn.
<br />l hrec and *rlln,ainrrin workErr ronrt isri,,n_rn\ursmc. a\ rcqut d tt Ser bn :lTm of rh. bbor Cod., for rhc pcrionmncc of
<br />rhc ux,k hn $hf,hthn mrm B b\dd Mv$' lrr nimFn\ahun 'n\u,ra.c.m.r afi]!.1'c) numbcrm:
<br />...-, -510L €;)
<br />*'",""-*, -?/ 7 72/ /a/;//a
<br />I.cdrlirhrrrnrhcp.rfoflmftcofrhc*.rkr(rwhrhrhxlt nir N ls$nl.I shlllnor cnrployan] pcson iruny mrnn.r
<br />$ r ro 6cconc subFcr ro rnc $orkcB compcnsation Usr o, Crlilbrni!. rnd r3rcc rhrr ill sh.ulJ tf,rotu \rbj.{r ro rh
<br />(or(cr\.ompcnqiionprevkionsotSccrion.lTO0olrhcl.otnrOnlc.l\tu'lltunhwiihcon,rlywirhth,*poviln,ns
<br />I{ARNING Fdlurc ro $curc workcr\ conrpcn$ri.r ..ttrigc i( trnhslul. rnd shrll \uhtcd rn cmtloF. ro cnn dal p.nrlri\ rnd
<br />civil fiEs u,r Io otrc hundr& Ihousrnd dolh (Sl(x).(D. in addnion ro thc co$ ofconrp.nsrlion. dnm,ses $ prcvidcd tur rht
<br />Scclion :1076 ofrhc Lahor Codc. inlcrc{ rtrd dlortrcy s
<br />-Z4O:6
<br />lJ.!Lll!!U!)\
<br />n tu ttxli,rcs md Pot$ninsCodc. ifrlrnv li.cns n in rrllrad v""ry? 03/
<br />3o-;4eA
<br />I h.r.hy xlllr unncrpcnrlryoi0cturyrhxrrh.rclsr.on{ru.lit)nLndirErgctr.yturrhcr.rlnnnrmcofrt*orknt*h.hrhnNdirn
<br />k\ucd iscc :109'7 Civ C I
<br />A.TIUIANI.D&CLAIAIIQN
<br />I tf,rhy urtim undcr p.nrhy of pcrjury om ofth. rollowirS dccltrrlions
<br />t)crmlirion P.irnils-Asb.sios N.rilicarnr Fcd.ril Rc8uhrbns (l'klc 40. Pd6)
<br />-Rcqutcd
<br />L.rtcr of Notift otion
<br />oftlinrncr\ md SIrrr lf,ws rc .or{'x.ri()n. rRl h.r.hy rfl l$'ilc 'aprc\rnrdirc\ ofrhis ciry Md Cl)u0r) b cnrs, uor rhr
<br />l,or. trknri,!r.d J,ro|tny lni i 7se:lf
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Sublloor/Vent/l nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulationi Eneroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ir/asonry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL
<br />Certificate ol Occu pancy
<br />Notes Remarks, Etc
<br />Set Backs
<br />UFER Ground
<br />Pool Fence
<br />Flood Zone Certil.
<br />nAl
<br />-l
<br />ccniiyrh{rthc fcdcrrlE8uhrions EEmlirE ashcsros rcnn,vtrl drc ml nftli.lhlc rorhh froicr
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