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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER DUILDER DIiI,CAIIATIoN
<br />I hcr.hy dfllrm und.r p. lr!.frrjnry lh! I!Dcxcmpt li.rn thc Co rndoN Liccnsc Ljr lor lhc rbllowins !$v,n (Scc'70315
<br />Busincss d Ptutursi.n Codc): Any Ciry or CounrJ, shnh requtcs I Frnrir ro .oosrto.r. alrcr. improra. .tnDlhh or rcpsn rny
<br />druclur.. firr h ns issuan c. also rcqun sthc rrnli.mr f{n such pcmir k, filc, \i8n d {rhmnr rh tF.r sh. it li.cnscd Nr{,nir
<br />ro rhc pmvistunt .l rhc Conkr.rols Li..nscd Law (Chaprcr 9. Comornrins trirh Scciion 7(XX) oa Dilhion I ot rhc Bnsinc\s rDd
<br />Pbfcsnnr\ C{ic)orrhil hcorshc iscxcmpl lhc.cfronrrM Ihc}a$i f{tr rh.DllcSL.dcxcnr lotr. nyvn.liotrofsccliotrTOll.5h}atry
<br />aplli.od 6r,l)cmiir suhjcarhc appli.anr fu trcirilpcnllryoanor mrclnatr ivc hundrc! dollun ($5([)
<br />l. r\ owmr oi lhc IroI.dy. or my cmployccs rirh *.8cs !s rhctr ek comnctrs o.. lilldo rh*trk ml rtE $durc is rel
<br />iNcdcd or ofr.r.d foi srlc (Sd 1044. au\ircss trtrd Pn,tc$ions Cod.:'fhc Conracd s l-iccn\c ljw docs noi applt b an own rof
<br />rhc U.lury who hrildr or inqrmvcs rhctu,d. trtrd *lm d{rcs {'ch wo'k himscll.r hcEcll'or ihn)ugh his or hcr o*ncDpk,!cc\.
<br />prolid.d rhll such imfmrcmnls m mt i cntn or oflinl for rL li h)w.w. rh. t{,lji,E or irlroEnEnr is stl wirhi'r nm ttr
<br />or.onflcrion. rrr owm, Buius *ill hnvc rhc hrd.n oi pmvinB rhar lE or shc dij mt tnrikl or in{rorc tnc pmtEny for rhc l)uqns ol
<br />_l.rs.$rcrolrhcDro|Eny.rN chsivclycotrri.rinswirhliccns(d.odkr(,^rocoiirucrr).p(&c(Sc.7(N4.Runtrcs
<br />ond PDll\sbn C.d.: rhc C. tNr'\ Li.cn{ L"s dors nor t)p1yn, mowncr oipn,rcrrywho huildror in,p.ovcs rhcrcon.
<br />and *ho conrE.r\ tn. such !!oJc.r sirh! ('.nrmcro(s) liccrscd lunur brhc(nflrrr.rn s Li.cD{ l-rw)
<br />I rndcmfr D rr S.crion
<br />}IOBtrE&I(AIIENMIIQN
<br />DICLA.BAIIO
<br />I h.rchy rllirmutrdcr |{nrlrlol |t.juryoncollhc f(rbai'rB d.clarurnnrs:
<br />I hrve ond *ill minrrin r Cenificarc of Con*nr ro sclr l,rurc r(tr lbrk&f .omp..sd i( r. as pmvidcd li bySccrnr1700ofrhc
<br />Lf,bor Codc. io. rhc Frfonm.cc nfthc work for shich rhc pdtrrir h irsurd
<br />'g+IrJ'onp(tr\alior irsurincc {ricr rxl Jrnicy nunrli<r !rc:
<br />t-..,
<br />ft"ri.vr.,,,7
<br />_l.cnify rh.r in rhc p.rforroncc.frhc work for which rhh pcrnrir is Gq&1. I shlll trot c,nploy any rer$n in.ny mstrncr
<br />s ro becom shFrt lo lhc wo cn'compcnsdi.n l.*sofcnliLrnia. Md 4mrh.r ifI\hould h.ronr \xbj..i k,rlr
<br />workrs compcnsarion Imvhions olSdio.lTu)olthc Lfitr Codc.l sh.ll. tudhwiih c.rnfly wfth tt.r pmlisiotrs
<br />WARNIN(; Failurc b ecuE worker conu.nsllion mlcrisc is utrltr*iul. trtrd sholl sunicl rn cmploler lo sinrinal rEnuhic\ lnd
<br />.ivil nncs ul) lo onc hund.cd rhrusrnd dolhr (!iloo.uD). in ddirion ro lh. con ol conp.nsation, dun'8cs as provnbd for lhc
<br />v]*,,?rrUficr ":;',;#ti.
<br />4. ^des (o.&*-&f,- <(\ ,z LraE\stsh coNt R,rcroR
<br />I h.rchy trftrm und* pcMtry or *,p,r ,n, ,,r,o-* ffi**H,'Hchaflcr 9(commncins wirh sccrion 7rx$) orDivtion.l
<br />ot rh. Bx\inc$lnd Pnrfcsions Oxlc- ud aryliccnk n nr rull fnrcc rJxl clf..t.
<br />t1 I o 1?871.rTreir+ t;fr"LG ^"L,.. G^ttr-rtu-a^c
<br />g)NEIf,UC1.|AN.LENDIXG.trGDNqI
<br />I hcrchy rffirm u,rdcr F.ah, or r.rjury rhar rh-rc is r.onntocrn n bhdinE l8cey for rhc ri{rfontucc olrlE sork for whi.h ihis tEmn i1
<br />issucd (Scc.109'7. Civ. C.)
<br />AITUCANLDLq,INAIION
<br />I lErcby llirm u dd$ rnnhy or p.rjrrt ond orrhc tullo{in8 dcclndn,rs
<br />Dcnk,hi Permirr Asbcsros Norilicarion Fcdcml RCEUhrn,N (Inl. t0. Pnn6)
<br />Rcquirud tf, tcr ol Norifi crrion
<br />lr.iil!rlirrrlr l.tur rguIr()r\ r.grltrrg r\l^-nr\rrtrrrr r.nnl,Lfti.'hl.kir]r\nniic.r
<br />lccniftrhrrlhNclcrdrhnlptli.arionarxl{rrcrhdrhcah,v.inf(,nhri rr\.orc.r Irgkrro.r t*irhrllC ynndC.niry
<br />ordiMn.cs md srarc ljN!rclarin3'o buildin3 consrn.t ion. d hcrcbyaurhorizcrcprcscm.rivcsorrhhCny,ndCouflrrocnrcrupotrr,r
<br />7".,.2r19tb
<br />Set Backs
<br />Forms/Steeli Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Su bf loor/Vent/lnsu lation
<br />Rool Sheathinq
<br />D tl
<br />Ext.i lnt. Lath
<br />Brown Coat
<br />It4asonry
<br />Pool Fence
<br />Handica R
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL ?.ZC-/E I J/eS >12{t9
<br />Certif icate of Occupan cy
<br />Notes Remarks, Etc.
<br />3l lr I aorq
<br />x.""."
<br />t ndeis Addr*
<br />Shear Wall
<br />Framino
<br />lnsulation/Enerqy
<br />T-Bar
<br />Flood Zone Certif .
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