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BUILDING- INSPECTOR FECORD
<br />SITE-WORK DATE COMMENTS .( )\VNI,:ll !Ull,l)liR l)Ll,CAR4l l()\
<br />t hcrcby rlnfln undcr pcmlly of l.rJnry rhnr I n.rcnDI lj{n lhc Cdnra.ur Liccns. trw rit rhc lbllo*ing rcFnr rs'c'7rll 5
<br />Busi'rc\\ rl Prnt$io. Codc): A.y Ciry ot Counry which rcrluncs I ,c,nrir h con(tucr' rlrcr. imlrovc. d.nrlnh or rcFn Jnv
<br />{ .rurc. prior ro irs t\uu... J\o rcquncs lhc atrltmr lnr !u.h Pcrnril lo filc tr \i3IEd d cm rhrr h. or shc k li.enscd Pu^urDl
<br />lo lhc lolirbtu or llt Conrrlci(tr s l-i.ctrscd tiw (Challcr 9. Conntncir8 wirh scdn T(xn ofOivisio' I oirhc tlusinc\\ d
<br />lh)rcssionsCollc)orlh.rhcorlhcscxcmplrhclclromandrh.h.s^lirrhcrllctcd.r.rPlion,^ny!t,tri('nolSccrirnrToJl5bvanv
<br />$flicorr ior a p.rlnir subjccts rhc aPplica.r ro d.irilpen!llyolnor nrrc rhanlire hun&cd dollds (J5(x))
<br />t. $ owncr of rhc pmp.rly. or my cryloy.ts wirh wtrgcs as lhcn sb coqEnsaiion will do irr sor k ond tttr srrhm ir mr
<br />inrcnLd or ollcEd ri, eh (aa ?Ol4- Busincs r.d Prcfcssions Codc: Thc Conrrcn, s Licctrs liw do.i mi apPlv k'
<br />'n
<br />owrcr ol
<br />rh. t6Fny whn tuildsor i'rForcs rtrrmn. dd who drcs sKh woli hnnsclror [cr*ltor rhrouSh his or h'r '*ncdDlorecsprovidcd rhi such nryrcvcnEtrls ft nor ir cdcn or oficFd r(, slc. li howtlr ltr huru,ng or im,xntmn' is sold *nhin oh' )td
<br />;rcomdclio.. rtE Osn$ Bniklcr will krc lh. blrd.n or lmvinS thd tr or snc did nor toih o, nnrrok dE lmlEnv aor rh' purlns of
<br />L as o*rE! oi rhe pBp.ny. 0m cxclusivcly conbtcrinB Eirh li.ctr*d c.nbdo6 to onntu.r rrt pojcd (Scc 7044. 8tr\im(
<br />aftl lhrcsirn Codc: Thc Conrracror's Li.cnsc L0* des nor trlnly ro an owncr o t riop. ysho tuildsor im[ovcs thdcon
<br />and who coor,lcrs for su.h pml.{ls wnh a a,fisct'nn lic.nsd Nnua t'rhc conradol! Li'cnsc L0w)'
<br />_l rDrcrcmpl uM.r Sccrio
<br />D.l. _ _ O*n€.:
<br />woxxrriiit:ortlm'nsltr irl
<br />-
<br />PECLABAIIOX
<br />I hcrcby rfimund.r pcnaltyotp.rjuryom ofrn follovi.s del@rions
<br />-lhav€mdwillmdinlainaCcnificar.ofConscnlloSclltn\urcforf,orkcm
<br />compcnsalion. is Provid.il ior bvSsrion 1?oo orrlr
<br />Lltbr Codc, f(, I h. pdlotmrc€ o, r& w.rk ld *hich lhe lcrmil h hucd
<br />-l
<br />hav. rlld will mrinloin vork.B conwNurion inslrutc as rcquncd b, Sdnrn 3?00 ol lhc Llbor Codc. tu rh' p'rfonuDcc or
<br />rhc w6rk for *hich rhn pc,nir is issu.d My uortcn odp.nel ion insunncc cmicr md Flic, nunb.r e
<br />8.",< h"rr l. /(
<br />(s-rsc, l/o EJ
<br />IccdifyrhnrnrrhcNrlorouncc.frhcworkIorqhichlhi\I)tnnirrsis$cn.I\l lltrot crnlovrnyF_i\on in,nv rriicr
<br />turstuhc.on.su6jc.rbrhcwo*cr'con{tisrrnrnhqrolCrlllnn,ir.3ndrgrccrhrrill\houldttconEsuh].'rhrhc
<br />*olkcrs.or,!.nsarin|x,vsbnsofS(ri,n:lTtDorrhchlitrCodr.l\hdll.ionh$irhconrPlyrirhrhosPnrrnions
<br />WARNIN(;: irilrtrc ro scurc sorkcrs .omFn\aibn c.rcrrB. i\ utrli*ful- md \hrll suhiccr ,'r cnrll.)_cr t' siminrlrMll'\ rDll
<br />ciril ,lic\ up ro onc hunilrcd rhou\and nollffi (SI0O.U)O). i'r &ldirirr Io lhc.o{ oi coDnrn\rlnnr. drn gcs !s Pxri{ldl lnr rhc
<br />Sccrh .1076 ofuhc tibo! Codc. iorcrcsr .nd .uomy s I
<br />""'"."h //tr
<br />I h.eby illirn und.r pemlry or pcrjury lhlr l z lNr xndcr J,ori\nnr ofClRfrs 9 rcornn.i.i'rg qirh Sccri(,n 7(X[, ol l)i\hn!r ]
<br />.l rhr Buri,rcs\ rnd Proic\ rRCodc. ari my ltc.\c t infulllorcc ifrlcfi:..r
<br />Q1LE2l
<br />,,,,,)lzll-E c-,*"- 5T Srr< .Serr/l '-( c
<br />CONIIBIJqflTNIINDIITG.AGEIII
<br />I hcrcby ulfirn rtul( If,Mlly of perj!ry rlur rhcrc is a connNcln n b.din8 !8cncv nn rtu lcrfoamncc ol rhc work l'or *hi'h rh Fnnir h
<br />issucd (Scc 109?. Ci!. C ).
<br />Set Backs
<br />Formsi Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/Vent/l nsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framinq
<br />ln s u latio n/En erq y
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />lvlasonry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certil
<br />.,i\
<br />FINAL bt7-tv xJL{ld',
<br />Certificate of Occupancy 17 \a_-7
<br />Notes, Remarks, Etc.
<br />ID/SIG.
<br />T-Bar
<br />ql3"/t r
<br />tJ .r'. \amc
<br />-
<br />AffIICANLDECI.ASA TN
<br />I h6rby 6nim undcr p.irlry ol ,crjur, ot of rhc followin8 dccl@r iongl
<br />Dcrmlilion Pcrmils-As&nos Noific.lion Fcd.,ol Rcgulnlionr Ont 40- Pn6)
<br />RcquiEn Lcrrc, ot Ntnific.rion
<br />-t.cnify
<br />rhd $c fcdcrol esuldrions ESddins $tEslos Emovtrldc nor lppli.dbh ro rhis ImF.
<br />Ieniiyrh lhlvcErdrhisapplicaliontord.rcIh.rrhcaholeiorum,tionis.ordrIagr@tocomllvwilh.llCnv,ndc'untv
<br />,*r,u*". una Sr,r" r,*" "ror'nfii" huld'ng coNrudnn. and hcrhydlhorn rcPrcrdnrariws oa thh Cnv and C'unlv ro cmcr u!'on lhc
<br />\\ _ , -)_ *,,, -? l> f /?Appu.0r or As.nr slEn,ru. ;r-l !'
<br />Pemi,(mftip n,,: U5sn fP--f
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