|
BUILDING. INSPECTOR RECORD
<br />SITE.WORK ID/SIG.COMMENTS OWNf, R BtIIT-I)f.R DEL('ARATION
<br />I hq.by lmm und.. poalry ol p.rjurt lh6t I o .xc'rpt 6Dm rhc conr[dod' L'..i:. lrw for tlt tullowins rdon (Sc.70]15
<br />adin.$ ,n PR f*ion Con.): Any Cn, or ( ounty *lih r.quir6 . F.rit ro oBrtud. .h6. inp.ort, dcmolrh ur icpar rny
<br />Md., prnr 'o i i!Ue.. rUr qut6 rlr.pplirr ft'r rkh Fntu ro nE, !is,.rt tl.rtur rhd lE or.h. a ti.rud puE|n
<br />6 r& Fsrih6 o, th. Connr.'o, ! l-ens.d L$ (Ch.prd 9- Comdrs *nh S<ri.n 7mo of oivtbn ! otrh. BuinB rnd
<br />lofcsiod Cod.).r rhr lE drh. b.r.qn in(c6om.rld rh. b.!i! ior rh. rlhs.d.rmpiion Any rbt,lhn 6rs.(bn 70:r I 5 by r?
<br />.ppli.mr aor . ptrir iubjers rh. lpplicanr to rcivilr.Mhyornor moGrMn nv. hundr.d dolli {S500)
<br />l. ! Nc orrlE F.Fny, q my cnpblcr snh w.a6 a lh.ir bk onr.dr6'! Idrrli*(trddriME!nn
<br />id.ri.d or oila.d tu nl (sc 70!t, BuiE rnd PmfBi.B C.dc: Th. codndd, Li.e La &E @r.p?ty io.i owEof
<br />thc pnlp.rry wlF boilL or iorr!\E ltEEtr .r!d *ho d6 rdh $o.t him(lr or h.elfor rtmryh hr n h.r o*n .npk yG6.
<br />pr.vid.d rlul ruch imFrcmtu r. ml hr.f,d.d .. oltird tur d. I[ hor*a. th. builcii| or ifi9ib@. n &L winin onc twofonpkiior tlE ouF Uuila rill h.w OE h,rl" orFnvi{ th.t hc n !h. dU mt build or i"prerc dr. FoFry 6. tlE DdDG. of
<br />l. c owffi of rh. Fopdr, m cr.bnrl, colIr..rDe wirh lktu.d codrdoE ro @Mdd rlI FDj.Er ( sc. 7044, &sdE
<br />!.n Profsbn Cod. TlkConrtclolr l,ic.nF lr* doB mr rprlrro uowonorprcp.nr*ho buildtor inprovBlhrcoo.tnd rho codncit for skh rrnjdr snh r Co.tr..ro(!l lt.ed puBu to llr Co ndo,! ljcd. L.r).
<br />I m.r.mpr undi Sdion .B &PC forrh. r.&n
<br />D.l. o.n.r
<br />laBa88tLcaMlE$urlq!
<br />DECIA8AIIO!
<br />I ha.by .trm mrL. !. nyorFiuryoN ofrlE folhsi,u &.L[lnB
<br />, hrv. rd * ill roi.uin r ( .nrfK.r. ofcouor ro S.lf'lBur. for rcrtdr omDdnr bi, ! Dmvid.d for by Scdion 17m olrhc
<br />l,h.r ( od.. ror rh. pafomnc. olrt. ,ort lor *nkh rh. p.mir i i$u.d.
<br />Ih.\ruxlurll 'nr.i. srrar'.omp.Err. iNdrc.6 c{u@d by s..rio.l7@ oarlE l.bor Cod..16.th. Frffi of
<br />rh. *mt acwfiih'hi, Fnr ! ue.d. M) *o'Ldt g'np.d.n M...6 &i pol(, nunbn h
<br />c*,- ' tfA(E 4.v4? T.J >
<br />;;";; -1!oq001 ,.,^,t -'/-rb
<br />I c..itlhll rlh.ldfomtr.of lh.wod for whichrhitpcmn ir bru.d,I sh.ll nor ophy.nyF6oh i.r.yM6
<br />s o t. b.com. tubjet to rhc wo*6 comFMlion |rw! oac.liaohi. .nd .sR. lh.t if I should b..on. lobjd ro rh.
<br />*orla @mFurio. por6irB.rS.(Dn ll7@ oarh. llbo. (od..l iEll. ftlntB ith conply with rhos poritr6.
<br />WARNINC rrihR lo Kw vorl6' on'p.dion 6rdr. ir u.h*tuL .rd rh.,l eb,.n .n dphF lo oioidl FdE.tn
<br />cnn finB u, n. .m huni'.d r}rruqnd dolli.t
<br />S(hon:1076 or lhc l rt-r Co!i.. trr(.{ i.d.rh
<br />(tl()O.om). !n..6nbn N ,qj.@rs.. dlmid s pr.\d.d tu th.
<br />!}!_tsll!
<br />I hn by rllm undd F.rx, .f Fjury rh.r I b li6a.d und.i Ftrvnion ol (lupr6 s t cornmcins snh Sdhn 7mo) or Dilbion l
<br />na lh. Bci.d ind Por.siioB ( odc. ud my lic.c. is in tull forc. rnd .fIft!
<br />'afi*: 1 Ob''ffJ
<br />I hdlby .,Im ud.r Fdly of FrJUry rhd rhr. ir . 6dnrdb. l6di,B .sny fi, UE Fa(fu. oatnc *nrl 6r uhi.h lhi! Fhn ir
<br />ixu.d (Sr.1097, (-ir. C ).
<br />APPLICANT DECT,ARAA|oN
<br />I h.rhy .rm und.r p.nllty or pcriury oft or rrE aollowios d(LnlioN
<br />D.mlnio. Poirl^rbdto! Nd'a(dFn FGd6.l R.suh ioN I TnlG .lo, Pu6)
<br />R.{ot.d lr{n of Ndii.dirtr
<br />lc.nif, thd rh. f.dcrir.ruLrnrB rcrdd'n!rmrtl!r. iot.ppl{rbl. ro rhi! pnlrd
<br />l.drtr l tr\. r€d rh6.p,'lk.rir..,rt rr . i.aornll nn E c.tr.cl I tsa lo compl) $ h .ll Cnt rnd aounr!
<br />ordrn.6 !.d Sl'l.lr!! rcbr'nBr(, buld h..by!ulb.n!rF6.d n6orrhnCirt,ndCou,nyrooiaupontlE
<br />.lir. rc rtr)ncd n'fltnv lnr Bt(rkrr
<br />,\prlidni or ,\E. i Si*nrrur.
<br />P.rEll..n.D.(p.inl):,L-oeA
<br />\t- tz't9
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenUl nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<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 />Engineer Final Report
<br />Flood Zone Certif. f'?ZILA K )Calt .{G GAll_€G6
<br />FTNAL-----,-I.*w I
<br />Certificate of Occu anc
<br />Notes, Remarks, Etc.
<br />L€D
<br />DATE
<br />,.. ll -rz - r<
<br />ry
<br />Rev 08-O7-2011
|