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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE IDiSIG.COMMENTS OWNER BTJII-DTT DELCA&1'f ION
<br />I hcrchy llfinn undcr pcnrlly ()l pcrtury lh l !n cxcnDr liom rhc C.nrrlrkri l,icco$ Itrq for rh. tdk,ting r.ry,n (s&:70:ll 5
<br />Brsiics rnd trctsn,n cl)dd: A.y Ciry or Courrr" shich rcquirc\ r pcnnir b con(tuc'. rlre. inpr.vc. dcnxni$ or Rpdn rtry
<br />{ .tur.. pi(tr b ir\ isurncc. al() rqonc\ rhc pplicrtrr f(tr \u.h pdnir n, lilc r silncd {dcmnr rhol hc or shc is li.ctr{d nnrsu!trr
<br />k, rhc pnrvisnrns o, rhc Conrra(ttr\ l-iccnEn h* rchnprcr 9. Connncn i'rg wirh Sc.ri,n 7{,fi) of Diri\n lofrh. Bunncrs nnd
<br />Pr.fc\rn,n\Codc)orrhrrhcor\hcisci.nrtrrhcrcfn,n,!trdrh.br\i\nl.rhdrll.gcJ.xcrtron A yviol.li.trolSslio.T0ll5hyrtry
<br />rmlrdnr rd,lrn r\ub..rsrhc rrpli.rnr r) JcivrlNtrnlrt.rnur nn,crhrtr livc hutrdrcddollin (S5{x)).
<br />l.a\ o*n.rolrhcnorcny.ornrycn,Il{Dt.\$irh*rscsr\rhcirv'lccotritctrun,n.willdorh.w.rlddrh.iMtuRi!tr r
<br />inrcidLn oroncrcd fr {tu (S..7(}lt, au\inr\srnd Dl,rcsi,nNG)dc: lh- Clr ra.tr'r Li:cn\c hs docs nol alplylo rno{ncrol
<br />Il[ pRrr.n! *ho tn'ilds.r i'ryroR\ rhcmn,, x l * M n(f,s $Eh rlnk hi'nscll or tu 6c ll nr ihrcush hh o. h.r oqn.mfk,yc.\.
<br />lnvidcd rhar su.h iDprrcmnhirc nor nrckh .r.flarcdi(r\rk ll ho\crcr. r lE ti!ilili',8 or inlpmlcr issldw hinom,tu
<br />ofmmpkrn,n. rhc O*mr Bdiu.r willhrk rlf htrntn ofpfl,vinE rlBrh.or \hr dil n bnuur i,rnrorr rhc pmt'cny l'orrhcI)U Inrol
<br />L nsoancrdfrhc piopcnr. m.r.lu\ivclr.onrrd.rnis \irh I'ccn\d .oitr.kr\ k, (on(Dcr rh. nroj.o (S!r Ttpl.llu\irus\
<br />,trrl llDfsstun(ndc:rhcConri.roisLi.ctrscLiwdocstror.nplvh osmrijlnr.ncny*hohuildsorinumtcsrlrr.o.
<br />n d $ho cnnrrcr\ ftn \dch In,l..r\ qirh r C.ntrhl\) I'cc'ncd pur\urir t'rhrConkd.tn'r LrcDsc tr*)
<br />tr ,,*.".(
<br />DI];SI,ABA.IION
<br />I h.r.h!ffinnu.,l.r pouhyof r^-^rjuryorcolrhc lnlkrvi'r! dcrlnrnrn :
<br />Lrhtr C(xlc.lnrrhc pcrloirn tuo olrlt $ork lar qhi.l, rfu ,lcnnlr i\ i\{rd
<br />lhc work inr uhich lht pcrnrlr i{ nsucd N1y $orkcr' collrnctrsrri.n iD\urrrcc caricr an lx)licy nom}'.r rr:
<br />l..nify rhrr in rh. p.rlarnBncc ofrh. work Lr whi.i rhis prnnir r\ isu.d. I shnll mr.rplo, any pcson in any mlnncr
<br />\o asro bccom nrbjc.t ro thc uorkcs compctr\di(in ln*s.lCrlininir, n lAEc rhd ifl should iEom suhFcr k, rhc
<br />workcF conr!.nsalion lroviin,N olScdio.17{Dolrhc t-rhn c:frlc.l\hrll. Ionhwirh con,lly wirh rho* pR,vi\n,n\
<br />$ARNIi"C: rriLrc b {.u.. qork.r\ c.tr,p!tr\r1i(r ..r.fuC. i\ unLr nl \hnll \ubj.cr nn cnrdoFr ki lrirninil Fmlri.s ud
<br />cnil fin.\ op k, .nc hu rrJ rlnus dolh^ (Si([).lxxr). i'r rJdir c.Dn ofconqf,nsiriotr. drtruscs !s pnvidc! nn ihc
<br />nlcrrnr drtu cr \ rr.\
<br />d r ,rppri..,r, K
<br />IECI.AB4IIQN
<br />Ihercbyoliirnundcr pcnaltyollErjurrrhal I ! licenan undcr prevti,'o oiCh{r.r 9lc.'nnrming wnhsc.rion 7000) olDivkion I
<br />of rhc Bu\irc$ rnd Pbfcsions Codc, rd my liccn\c is tu tullincc0nd.iltcr
<br />C:OIIIXIJSUANIENIIING-dOENCI
<br />I hcnbydflir u.df p.iahyotFquryrhrt rlB0 ir n.ornrucri..lcMinS rScnry hr lhc pcrftnum. olrhd uork tor shi.h rhi\ !.iinh is
<br />i$ucd (Sc.:lot?, Ci! C )
<br />A.T&ICANLDICLAAAIIAN
<br />I hcrcbyannNnndcr pcD,lty oipcrjury orc ol rM t)llowin8 alnrurioos:
<br />D..Dlirn,n Pfnirs \h.{os Norifi.dri$ lrdodl Rceuhrn r\ ( Iillc,t0. furl6r
<br />R.quiftd k($ofNohfi. ion
<br />(TP't' 'hn 'ft nr' ' "E t ri''
<br />/Lr&d fr rhJ lhr\c rc,trlrh \,,nnli.,(
<br />onli'rn.c\ xtr srrrc u*\rclrr st' hui
<br />c rrudins astc(os rcmulrrc nor lmlhnblc ro rhn pmj.tr.
<br />ion aid narc r!,r thc rh,vc nrrorn tr tcor(t.l ase Io conuly *ilh Bll Ciry snd Cootrry
<br />$.vc mnrnlrcd proncny tur invccr
<br />AppliMnlor *ent sisntrtum (
<br />Pernil.e n.i! I pdn0i K /,>.-o
<br />,"r,""tr,,t'","r:_a-tr:y;l;-*
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Tloof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Eneroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />It/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />FINAL x-2*-lY v,v.A40
<br />Certificate of Occu pancy 17 v
<br />Notes, Remarks, Etc.
<br />: W gda o-u !/S66|L
<br />Li.c.sccla$: Li...sc Numb.r:
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<br />Dir.: ConlRtdr:
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