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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL et E
<br />Certificate of Occupancy
<br />Notes, Remarks, Elc.
<br />OWNER BUTT,DER DEI,(-A'TATION
<br />I hd*, lmm un&r p6 y .f pcjury lhr I h dmpl nlm llt Codt.cld U..e k* aot lhr lolk sis laain lSG 70r r.5
<br />aGiE .rd Piol66n Co&) Any Ciry o. Coudy whkt r.qon6 . Fnr lo o,t!tu<r, .ha, "4.oq ddmluh or i+.tr ay
<br />nru.ruc, FD, ro ii. ss@cq .to rqui6 lh. .pglket for $ch Fmi to 6L . lign.d niml thd h. or JE i licq!.d p@!,,
<br />ro lh. rovirioN of rlE ContEtd ! Lic.ncd Llw {(1trDta 9, com.nci.s vnh Sdioo ?000 of Divition 3 of lh. &aind ed
<br />PDfdi,c Cod.) d lhd h. or .lE i! aoF th6c6oE .nd th. tGi' for lL .lke.d q@Iion. Ant riohlhn of S<rion 701I J bv oy
<br />rpgltd aor ! Fnii subia tL @lic.n b s cirilFEhy oltul mr.lh., fiv. hutdttd &llE (1500,
<br />l. s osG ot lh. FoDqry. ( oy arl6,6 sih *.s6 s fi.n $L corpqtldiot! *iI d. rlE Edt rn ill rrttE i bl
<br />!{od.d ofiacd f6r $l (Sa ?044. ouiB Dd Pror6ioB Co<r. T1r (o,nr..id r Ltoe le.-. {,6 n<{ +1, ro d oqE or
<br />$. prDFry who hit& tr !r4.!E tlEEl! !d sho d.'- ech ${,t hihr.lr or hellor thrclsh hi. ot hs om atplotc,
<br />prolid.d rh such imFo\ErEfu & ml ilnqd.d orofrstd t'. ul. l[ ho*s€. rlr toilli,rB or iqmroEn it *,1*ithd on. )d
<br />ofotrptrb'! dr (xE &dldc vil11.lE hrdar o,Fori'B lhr lE q i! dd ml hlld s if,!.ow th. F,!9, e( E F,!.col
<br />-1.
<br />s o$G 6f rh. FnFry, m crcluiv.ly col'lcrins u,Ilh licqs.d otu&1or ro (nirucl llE ,ro,.l (s< ?o44.lllles
<br />!,n hokin Cod. l'lE co ido.r Lic.M bw d6 mr {'gly ro & 016 olFopdry elr t{ikL or hprcvd thd@tr
<br />od *t s dr aor$ch Fojrxr! *'nh. Co,naro(r lkns.d ruB@ h lh.( onr.dd't licB rn)
<br />I m.rmd unls Sdion , B & P C fnr
<br />'hir
<br />ren
<br />Drl.: ()*nn:
<br />WoRI(EILS, ( On PrNSAIION
<br />DtgtBAlM!
<br />I hqcr,) ,mm un.Lr FDht ol pajurr orc ofrhc folL$ ltl3 dd tlal oB
<br />I h.v. Md will mdinrai! r C.niakar. ol Conmt b s.lf-lBur. aor u,I.6' conrPmr.tion, s Ftrvid.d for by S.l ion .l7Ltr . f rh.
<br />bb.r (ixL. for dr Ffolrffi. oalhc Nn rd rt.h lh. Fmn ir isu.d
<br />I hlvc dd pill drrnlii( wo.I.rr comrEsrion iNuranc.. 6 r.qurcd by S..tbn l70o of th. r,bor Cod.. fo. rh. FfolM. of
<br />lhc work lor which rhs pdmir ir iBu.d My worta compdEd ion iBue. cmir !'d Poli:y nurbq &.
<br />- i6q (61|n17 J \c
<br />Vqwc lqqqBq
<br />-l
<br />.d'fr (h{ in th. Ffolrr8. of lh. *o,i for *hah $n Fnn n islal. I 3h!ll nol mploy in, Ftun in dy nuF
<br />s 6rolEom. bjarrorh.ed6 coq,aeion hpsofcllifohia, ed ascrhd ial lhould tE<offiluudl to tlE
<br />srrt6' coftpqsr irn For i.ioB oa Sln io. 1700 of lh. L.h. ( od.- I tJull, fonn* nh ompl, sitt thoe F.vi.ioB.
<br />$ARNING F ilur. ro su. Nrt6 comFsx,n co\6.9.tu|. id 3hll sbjrti n drphlq !o ainDl Frrb !d
<br />rilil fir6 !p to oE hu!'<h.d rho@d dolla (ll rh. cor ol <onF@roi. d.!EB6 a Fnv .n for rh.
<br />sRl n, 1(i7( ofrh.lrlrn(intc. tud8rntr
<br />I bortr, .rm u.dd p@.ny ol Fiuy fir I D liuu.d u.& Foliti,. ot CnlPls 9 (onlJjE'ie "th Sdb. 7000) ot Divilnn 3
<br />ot rh. lrui6 .rd ProfBio6 Co&, rn my ltde t i, tull loc d {rcr
<br />C-t 1 fos{o',
<br />lQl)r- lI
<br />lhftl,y lmmtrnd6 rErhyolp.rjurrrhal ln6. i.r , $nntud tr,n kndin* a36cy tor lfi. p6lon .nc. ofrh. "ork for sh'ch lhlq tEni is
<br />su.<l (s( 1097, (
<br />'v C.)
<br />APPI ICAN-T NECLA{ATION
<br />I hc*e aitm und6 FElly of p.rjury o.. oa rh. LlhNins d(l4tl ions:
<br />Dnmhb. P.mngAsLnor |lorificdron F.darl R.suldi.m ( rnh 40, Pd6)
<br />Rdt!n.d LdG of l'lolifErF"
<br />-l
<br />cd ify lhd lh. t6l6d r.suldirB ESEdirS Iw\duc hr 4plt bk tu rnb FlF
<br />_! rdr'ryrhd I ha. rdd ihis rmlicaln,n n,n iscotrd lasrek' conplt airh.ll( ily rnd Counry
<br />f'd'nan.6 ud srar.l.i\r r.hmF r ri,.rcD.e .ln6.lrhi. Cny6,n Cou ylo6lcuFrnfic
<br />.!o1. lmlioEd proFly fm
<br />\l'plicntrr 'n ,\g(trr si!arl 'r nn" \ t-r -17 - 19
<br />;EI
<br />Qcn\zt--
<br />tqtg,/it}IwNI
<br />PolicyNunbq:a
<br />l() -t-'l ,l 7
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