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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE tD/sra COMMENTS OWNER BUILDEII DELCARATION
<br />I hcrcby rififln undcr pcnrny of p.rjury rh l dm eicotl lrom rhc Conri.k,s Lt.nsc tja ror rhc followin8 tc!$n (scc.7031.5
<br />Businc$ snd Pofesion Colc)r Any Ciry or C.unry lhich r.qui$ r Fmrit b onslrucr. alrcr- ihln,vd. dtmlhh nr rcNn My
<br />ntudud. pri{rb ik h\uM... ako rcquncs lh. arplicd ro.su.htr rniltofilcisisEd dlr.mnr rh,r tr.r shc is liccnscd punuanl
<br />ro rhc rovisiuN.athc Contrucntr\ l,iccnscd trw (Chirrcr s. Coiln 'kine snh Scdio. TOOo of Dilision I oa rlt Blsincs rnd
<br />Pmtcr\ionsConc)orrhnr hc orsh. N.rcnrpl rhcr.rom Md thc hsis for lhc.llcEcdcxcmprion Anyviolarionors..rionT0.ll.5by!.y
<br />nprli.anrrnaD.inirsubj.cklho,npli.n.tloa.i!ilpcnallrolmlmorclhanlirchlndrcddoll6(S50o).
<br />-1.
<br />As owncrol'thc proEny. or nry cnrplolss Nirh waSc\ as rhcir s,le comp.isdion. willdo itE edk lrd thc ntrlm t ior
<br />i'ncndcd or.llc(n for slc (s.r.704:1. Busi.cs nnd Aofcsrions C,rd. ThcConrrNioisLi.cn\cLtrrdocsnorBptlyroMowncr.f
<br />rhc pmFn, who builds or in{,orcs thcpn.ond lho drcs $ch w.l( himsclfor hcmlror rhrough his or hn ovn cnlPloyccs-
<br />F)vidcd rhar such ifipfl)wnrnh rm mr inrcndcd or olti*l for slc lL ho*.{i rh. bdiklinB or nr{mrcnr ksklsirhinorcrs
<br />ofonDhlbn.rhcOwncrBuildswilltsrcrhchonlLnofpn,vingrhdhcorshcdilnorbuiklo.nnl,mwthcrnrlEnyfotrhcnuqneof'
<br />_1.N.sncr.lrhelropc'ly.amcr.llsivclyconra.rin8wnhli.cn\ddcont&tusr.cotr{ru.tllEpmi.llSs?O$-Bu\i"cs
<br />ml Pn,lL\\6n Codc: Th. G,nta.ror's Liccnsc Li* docs.or itpl, h.nowrcr ol proPcnt sh{) btrilds oi inrProvcs rhcrc.tr.
<br />.trd *ho cont.cls for such pmj.crs Niln ! Codrochl9 liccn\cd lu*utrnr t, rhc Conr..rof s Liccns. rju )
<br />-l
<br />amcrcnrpr unJ.r Sc.ri,n,
<br />".,1L- lD l& "*-tL
<br />uield&rltl]N
<br />! hcrch) rlli'nundcr |f,nalryol prjuryoic ollho lalk)s t do.l rnri(!Nl
<br />lhJlcandsilltrri' rinrCcnifi.rtcofC.nictrrt,S.lf.ln\urcfinw.rlcrlsr|Etrsrn,n.0s ptr,viJ.d turhySc.riotr:17U)ofrhc
<br />lrxn Adc, lor rhc I'crfornBncc of rhc sort trtrwhichrhc fm r is is\ucd
<br />I hrvc rnd willnnininifl sorkcrs compcnsatnnr insurrncc. $ rcquirci try Sccr ion ]7m ol rh. bho. Cldc, iirr rhc pcrforro.cc ol'
<br />rh. wolk LrBhichrhr pcirnil is hsuct. Myworksr ompcnsrriotr insurlncccricr Md B,li.y nu.lt{r dc:
<br />I ccnily lnnt in rhc pcrlorm0nccollhc work lor whhh n,t pcrn,ir is i\qucd.l nrlltror cnr oy trny peror in u, mMi$
<br />$ s h hc.om sh]cd r., rhc n,rk.6 .o'nFns,rion lasi .t Crlifonria. rnd tr8rcc lhar ii I should hc.o't $bj.d k, rhc
<br />works\' .onrFnerion ln,vist,ns of Sc.riotr .l7lx) ol rhc titn Cbdc. I shall. l'onhwilh conrdy wirh lho$ F,visions
<br />WARNIN(;: Fdilurc h sctrrc wolkcN (nnpcns.rion c.vcragc i\ unlawtul. and shrll jub]..r an ctnplnttt b dminol Fnuhn\ lnd
<br />.i,il ftrcs up ro onc hundrcd ltou\lnd douarr ($l(x),(x)o)- in lddirion k, ihc.di or.onlxns ion. dim8es rs [ovided lq rhc
<br />SR rnn .11176 ol r hc Llh Cclc. inrcrcl
<br />*-,(r4 l0- ((
<br />DDCLAXtrIIO!
<br />I lEEby aafirmlndcr p.MxyorFrjury rh{ I dr liaNd und.r !rclision ofChaprcr
<br />ol thc BusirEss Nd Pmtc$nnN C.dc, il
<br />'ny
<br />lic.ns is itr tlllLr.c drdcllcrr
<br />CON$If,IJEII()NIENDINCJIiTNII
<br />I hcEny olUrnrnndcr pcnllly.fpcrjory lhd rhcr. is n.onirucri,n Lndirrg r8cn , ror lhc pcrrofl.rmc orrhc work ror whi.h rhis Pcnnit is
<br />i\srcd lscc. l(})7, Civ C )
<br />AITLIIj/INUr!.CIA3AIIIJN
<br />I hcr{,y Jfim rnd$ p.nrhy oipcrjury orc or rhc rolbwin8 dclararion!:
<br />D.nrlirion Pc nir+Asb.sos Norilicarion rcdcrrl Rc8ularions (Tnt 40. PJn6)
<br />Rcquncd ktt.r of Nolifi cltiotr
<br />I crdifyrhr( rtu,idrrrl rclr!r(nnr\ r.Erdn! r\lrno\ rr $rlrt Do!qrDl.xhl. t)thn nn,I.r
<br />lcc iryrhar I hdk,cd rhtrmlicrrion0.dslatcll ihc0h,vc inbrftni{nr i\corc.r.l rgrN roconrPly*ilhallCi'!rnd C.umy
<br />ordimn.c\ind sturc L,*srcLrrrgro buildinS con(ructn,n- urd h.rchy ruh zdrcprcs.trrstivcsorrhnCirysndCounrylocnrq!I,,.rtr
<br />H:.:i#",.:$
<br />""-r**."rrn*,, Dd Uf
<br />o,,, 44 - lo - wtluaufu
<br />Set Backs 6-q-)g hY.tH
<br />Forms/Steel/Holdowns 6-S-)tr 4-W0
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq 7'L'/4 .J)eJtto'7s>
<br />Shear Wall 1 t ?,,l\
<br />Framinq I o/a/-u%.L
<br />lnsu lation/Eneroy 2 , , ,/tO aD-Aqwall .7-tL-tg W--v+)Lt)rExt.Int. Lath "7-!z-l{ fiU
<br />Br-own Coat
<br />*4asonry- Jt tdC't 7 -16-lv \,Wtr,))
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />,A
<br />FINAL {9-ty x.lL(lti
<br />Certif icate of Occupancv
<br />Notes, Remarks, Etc
<br />Li.cnsc Chss
<br />-Lic.ns.
<br />Nun'b i
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