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BUILDING- INSPECTOR RECORD
<br />SITE-WOHK ID/SIG.COMMENTS OWNER AUILDER DELCARTTI'ION
<br />I lNshy ainm ulldcr p.nlhy of pcriury rhd I .m cxcwl from rhc Contactx l-iccnsc tjp for Ihc lblb*ing lc.sor (scc 70315
<br />Bu\incsr a'xl Pn,fcssiotr Codc) Atry Ciry or C.ur, rhich rqun \ r fnnir ro $n(rucr. alic.. imprort. dclmlilh or rcJrat ony
<br />rrudutc. Friortu ns hsurtrcc. oko rcqrncsrhc rpplicmi nr su.h Pei,nirlo lilea siSncd {dcnknr rhd h.or shc h lice.\cd P!^uanr
<br />b rh. lm,vnn N ol rh. conlrrtols Liccnscd l,aN (Chlprrr 9, ConnENirrg wilh Sc.lion 7fin oi Divhn,n I or rhc Ansircss an
<br />Pinasid( Cdd.)orthrr lEorshc isc\cnur rh.rcfnDand rhc hn\is for thc {llc-ecdcxcmPri.n. Anyvi.ldionoiScclnnrTir.ll5l,ydiy
<br />.!pli.!nr l$ ! |EnDir suhjcck rhc qrtli.a lo a .iv il Fnalry ol ml nmrdh!. five hun&cd dollrs (S51xr).
<br />I.0sowncrofrhcpmpcny.orhycmplott.swirhwqjcsrsrhcnsobconrPcnsarion.willdorh.workardthcsrrud@nnor
<br />idcnd.n oroftercd|or{lcl5(.7044.ausitrcsrndProfcsion\C{ncThc(i,rri.lM\Lkcn€Li*docsnorapllyr.Mo*ncroi
<br />rhc nn,Fny wh. hnilds or in!rcEs rhc@n. sxi wlxl d6$chtr.il hini.ll or hctelforrhmu8h his or h.r ostr cmployccs.
<br />pn)vidcd rhrr \uch imnorn.n* m mt mlcdcn or oflt.rd for st ll lxr$orr. rh. huildiry or in{xxlnEnr is vtl] *irhi'r mk F],
<br />ol.omplcrion- rl.tr Osncr Brildcr will hrvc th. burd.n olprcring lh(l h. or sic di{l rn huiu o! nnpmE thc PDIEi, f{n rhc PUli,*of
<br />-1.
<br />n\oinc!olrhc pn,I)cny. rnrcx.lusivclyc.nlr$rin! wilh lrccns.d coikrctun ro.onsrrud rlE prcFr iSft 7Lx,r' Buqnc.\
<br />Pnfl\srrcodc:lhcCorlr0cktrsl.iccnsct-awdocs.rat!lybntroqncrolnropd,whohxildsori'nfrovcslhcEon
<br />rn(l sho (1lrrracl\nrruch pojccrs qith a Ginlrich(s ) licctrscd Purulnlbrhccoikr.ttr's Lic.flsc L.*r
<br />lr cxchpr untlrrS(r -.8 &PC finrhis rcx$..
<br />lllJx.6EIlS.:C0MPiNlArQ!
<br />DECI.AX{IION
<br />I hcoby aflirm undfi p.nrllyof perjuryotu orrhc blk,winB d.clarntions
<br />{r r','" ,,,0 *lrt n.in.in u Ccnifrclrc or Conscnr b selHnsu}t tot wotkcs comp.nsarifl,. d\ ptuvidcd lor hy Sccrion:17 )orrh.
<br />Irw Gdq trtrrhclcrfonu.ccoflhc $od( fo.shich rhc pcrmir n issu.'1.
<br />-lharc a will!.airran, aork.s coh|[nsdiotr irxuru.c, n{ rcquircd hySc.iioi r7(x)olrhc l-ohor G)dc n,r rh. Pcrronmncc ol
<br />nr.n{ ion insura'Ec.anicr dd Fni.y nunrhlr uc
<br />C
<br />-lccrrilyrnrl
<br />irrhc pcrtortuK.^c ufrhc work lor lhichlhis nlnnil i\ issur . I \hrll tror cNPloy any Ilcron rny Mtrcr
<br />v' trsk) h.comc \ubi.cr bIhc Lvorkcis coDprtrs"ii,nr h*\ .f Crlllanrir. trtrd rgrcc lh{ ii lshould btconr sublccrr,lhc
<br />worrd\.orFnsnrionFrvtiomolSc(i,,n:lTmorrtubhtrCo,lc.lshnll.l]tnhlirh..nrnlywirhrlkr{[ovi\i{nN
<br />W]\RNIN(| lailurc t, {curc sorkcr$ compctr\arnnr corarrgc i\ un[sru]. nt rhrll \uhjccr an cn,plottr t).ri'niiil P.'rlri.s Md
<br />cnil fin.\ !t k) otrc huftlr.d lhotr$nd dolh^ (SllX).(n0). ir r(Ldniot r) rhc ..( of co'nPct\rii,nr. drnr8cs as pniritl n nr rh.
<br />s(rnr:1076ol rlr trtxr (itrlc. irrcrr( od dlnmt\ lic!G--/, f/azg?-/?lr ,rppri.-,,).
<br />LM!t!D_(1) Ini!rc8irE(tlltalluN
<br />Ihcrcl'yliidun,lcrpcnlry.fFrjuryth0tIomliccn{nundc,prnvision.lchirrcr9{connrcncin!*nhsNtiotr?uD)olDivisb.:l
<br />ol rhc Au\imrs and Pmrcsioni a)dc, dxl myliccn{ is in irll ri,tur sqlrll(r
<br />?on{qz
<br />1- a- la conrntro..X 6Z-f44,:/O fui.e)?TTA
<br />C!)NSIBIJEIIONI.INTUNEAIENII
<br />I hcrchy llltm undc! F shyorp.rjurt rhd rhcrc t ! construcri{'n lcndinB rgcky lot thc,}crrbrm!..c orrh. sork r'{rr which rhi\ I.nni n
<br />^sucd lsc. 1097. Civ. C )
<br />lfflrcdnfD[rtaBAll!]N
<br />I lm{y dhan utucr penalry or Frjury otrc of rhc lorloqirs d(llnrtions:
<br />Dc.$lnDnPcirnnsAsbcnosNorifi.arionFcd.nl R.lulali.ns(rltlc.l0- Pan6)
<br />Rcquncd L.llcr ol N.lil-rc,rion
<br />lr.i'lyrh rhcl.Jcn,lrcrulornn\rE d'ngJ\hcr'* rnu!rl cnrt.'Cnrrhhrcrhhn'uflr
<br />truflccnrrvrl'dlhxcrc",rrhrrrnl'!,r d.trrcrh0rrhcotnlcinlorrorn,ni\.on.rlasrcclocomplyeirhllCil!rtrdCounrv
<br />T nd'nrRc!.n.| srur. llr\ rcLr'np ru burldrnp (onqn(r'utr. tuxl hc,cl'y surh.ri2c rcrrceDr.livcr oflhi\ Cir, rnd c.unrvlo cnls u,'.n rhc
<br />rbvc nEntioncd 0roFny tu inTc.rionF!#2 "",".?Lf-tr\t,Iln nnr r rx r\i$xrurr
<br />"*.U* "**,r"r,, X u vf<
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/Vent/l nsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq a,/I
<br />lnsulation/Energy (72q/rt ..yK)<-t
<br />Drywall L/
<br />Brown Coal
<br />lvlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certif .
<br />tt
<br />FINAL /o,b///q 2 tVqt,
<br />Certilicate of Occupancy ' / '
<br />Notes, Remarks, Etc
<br />-t
<br />DATE
<br />Ext./lnt. Lath
<br />- ll--Za- lr
<br />l.iJ- .
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