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BUILDING- INSPECTOR RECORD
<br />OWNER BUILDtrN DEI,CAR TloN
<br />I h$cby nrtrm u d.r l.n lry .f p.rlury rhd I nm cxrmrr frum rh. Cbnrn k,N' Lic.nsc tiw for rhe followin8 i.o$n (Scc Toll 5
<br />Bosinc$ stu Prolt$ion Codc) Any Ciry or Counry which r.qui.cs r lrflnir lo onsrruct. alrcr- inrolc- dcmoli(h ,tr rlJn r,
<br />ntu.rurc. Jri, k, iti i\soa'rc, aho r.qunerrhd arplicrnr f(x ch pcrmirh lilc r sigftd {.r.md rhrt tror shc h liccn*d pu uMl
<br />ro rhc pmlnnnN of lhc Conlracxtr\ l-icensed L.{ (Chtrttcr 9. ComnrcncinB snh Scclion 700(r ot Divhn,n I orr,t Bulin.ss r.d
<br />Pnntsions Codcl or rhar hco,\hc n crcmrl rhcrcli.m a.d rhc hisn lor rhc alkscd crcmpridn. Any liolari('ndrsc.rir70]1.5 by,ny
<br />drpli.anr [6 n p.i,nir subj(a rhc rrpli.nnr baciyilll.nakr"ofnor mohrhan nv. hundr.ddollrr\ (S5m)
<br />l. r\ .wncr of rh. pn)Fn y. or y.nfloy&\ wirh qagcus ihcn v,k m f.n$i i, . will dd rh. work rltlf{nErurcisnn
<br />irclxhororlcr.dforqlc(SN.701,r.Bnsi,rcssandPiordsio\(-.dcr'Ih.Cotrtr.toist.iccnscti*docsnorl'Ppl)loanoRncrof
<br />rhcpripcny *ho huil(h or iNnmvcs tlrtosn. dwhodoc({.hwo*hnnscllorhcr\cliorrhr.u8hhtorhcrow.c uloycc\.
<br />PR^i,tcd rhrr su.h inlPnncnuh m n inrc cd orolt'crcd for sat lll h)*.Ki thc hiklin! or nr9nn flnnr is {!kl sirhiioir tt{
<br />orconrrkrion- Ihc owncr lruiklcr wilLtuvc lhc hudcn ofrir(,virB rh hcor\hcdid n huikl or i'q,rovc rhc pn,lcny fit rh. NrrxM or
<br />I. isoqfcr frhc!(rpd y, trr d.lhivclt .rnr' mr n3 wirh licrtr{d..nklc(nn).oinnrr rh. trojcd (sc. rlr1i.8u!m\s
<br />r l\Dri{si)tr Codc lhcC.trrrrcntr s I i.ctrsc Lrs d.cs foli|plyr. utr.$ncr.lrr.ncny $h. huil&or i'nomv$ rhcrcon.
<br />rtrd $ho $ trd\ lnr surh l]fi,jcd l snh r CunrNh( n li.cn{'l nrr\ua rhrh.Coihrrhtr-s l-rcDs hq)
<br />;:-.HHi , B &+ C fdrhr\ rcalin??llq,"L
<br />I hcrcby ailtnr undcr lenrlryor rcrjuryom ollhc hllo!,ins dcchrrrionr
<br />-l
<br />hnvc ntrd sillrMiilrf a (tniaralc ol Cotr{ l. S.lf.ltrsur. fd *ukcs- .onlllcnel ion, .s irmvidcd for b, Sccrion]?00 ofrhc
<br />Libor Codc. f.r lhc r.dorm $ ol rhc *ork f(tr qhi.h rh. Fnnir h hsucd.
<br />-l htrtc and *illnai ains.rkcn conrF.n\olion inntrrrrc. is rcquircd$ysccri,n:l?(x)ofrh.lrborcodc.forrh.0crlonnnncc.l
<br />lhc wo* nnwhichrhis pcrnrir i\ hsucn Mysorkcrs compcn$rion iNurrn.e crricrudflricynu cr d:
<br />l .cdili thrr nr tu Nr for n.cofrhc$(rk tu whi.hrhi\Nirnir is n{icd.I\hrllmr cmtloy(nypcr{rintrDynuotrcr
<br />s Nrotf,coN s,6F-^r b lhc *orkcF' .o'nFns$ ion ltr*\ofCrllhnrin. a.i i8Nrh3r ill \hould hccom\uhi.r n,rh,
<br />$orlcB (n.pcnrlriopmvisionsolScdt,n]7lX)ofrhcllhrCoie.l\hrll-lonhsirhcon,pl,$irhrhovrRrnnN
<br />WAIINING l,.rlnrc io sccurc *orkcr comnctr$rior covcrrgc i\ trnhslul. rnd \lull suhjccr u ctrlPhycr n, oiiiinrl ncinlri\ nd
<br />civil rjncs up io onc hundrcd rhou$nd doll.n lSr(x).(xD). in irion ro ihc..{ ofconrpcnsrrion- danB8.\ a\,nr .d ror rhc
<br />Sccrnnr.l0T6otrhc l:'htr Co{ic- inlcr$l!nd ar4lzzl$
<br />I h.r.by im n uM.r rcnllr, ol tErjry r lu I rtr' liand undd r(,visi.trolChoptcrqlcorn,Encnr8 r
<br />of ih. Busftsand Pmfc$ionsCodc, dnd my ll.cns. is i,r fullttr! d cff..r
<br />_Licctrs. Nufihc! _
<br />caNsrauqullNrlMlN!;lliExq
<br />I hcrchy l.n uMo Fnnlrl orNrlury rlur rh.rc ls r.on(fl.Ii,n Lndin!,Cctr.y ri,r th. |rrr'ornrNc of rtu trork tr whlch rhh pcnril is
<br />is\uc{l lscc .lO9?- Civ C )
<br />AffLTAN[DICIABAIII&
<br />lM'y ifiirm undcr pctrilty ol pcrjuy orc ofthc folloqrng dc.lrorion!
<br />DcnDliiion Pcrmir$Asb.nos Norificrriotr Fcdcr!l Rcguhriotrs (Tirlc4l, P.fi6)
<br />-Rcquncd
<br />Lctlcr or Noli,icrlion
<br />I rcnifrrhrrrhc ltdcrrlrguhn)ns rc!nli'rg ,rhc{o\ rcnmvrl m nor rpllicrhlc b rhi\ pmj..r
<br />I cdirtrh r I hrrc rcdd rhi\ rlpli.diinrard ddrrhrrrhcrh,!c inf(rtrL i(,n is c.fu.r l rliNhconlPlywirhrll
<br />:,odinan.cs aml Sr c ljws rcllrin8 k)as.o.drucri,nr. and hc.chy 3uhnizc rcnE\rnidivN ofrhh Ciry ind Cou
<br />$ovc rtrroncd liirpcn, tur
<br />-t l-,lLeLL
<br />SITE.WORK ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathi ng
<br />Shear Wall
<br />Framing
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lalh
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handica p Req
<br />De puty Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />FINAL
<br />Certificate of Occu pancy
<br />Notes, Remarks, Etc.
<br />ONI'A r L\EI.!E:2
<br />DATE
<br />tr Jc' .
<br />^d,l'i..
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