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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARAIION
<br />I hcrcby rmrn und.r p.Mlty of pcljury lnal I dn crcnrPr tnnr lhc Conlrsdrtrr t-i.ctrt b* for rh. folloqins rcisn (5...70:11 5
<br />Busincst aRl Prot$b. Cdc): Any Cny or G,unry *hi.h roiluncs 0 Fanir lo .otrnrucl. olrcr. inrrrole. dcmohh or rcP8ir lny
<br />1iflcruto. prid ro irs issuancc.0ko rcquircs rhc aptlicatrr for such lcnnit lo filc r lisncd natn-nr rhtrr hcorsh. ic liccn\cd Nnamr
<br />ro rhc F,lnions ot rlk Conrd.ror's Liccn*d tiw (ch.Icr 9. Conrmemins wirh Sccrintr ?0OO ol l)ivi\ion :l or rh. Bu\incs ind
<br />Pn)rcssbn\Codc) urrh{l hcor sh. ncxcr.pr lhcrcfmnr r lhc bu\i\ fitrrhc !ll.g.d dxcnuln,n Anyvidnlionolscdionr03l5byany
<br />{flicrnrfor.tnnilsubrcchrhcopplics tor.i!illr.nllryotnorntrcrh llv. hundrcd dollffs (S5(xt)
<br />_1, a\ owtrn otrhc Frpcny, !m.rclusivcly.otrtd.ririg sirh li..trscd cunlrrlMsro connrcr rh. [o]cct (Ss. ?044. Iruiir'c$
<br />Md Ptr,fcssim Cotu: Thc C.nracd s Liccnsc tiw doc\ rcl arply nr ff owi.r ofIrn,nrny rho htilds or tnptuv.r rhcrdnr,
<br />anJ qho co.trocr s for su.h pm]c* wnh , Cotrrft.k,n r) lic.nscd lxrsurnr b rhc G r.dol s l-icosc hw )
<br />I $r.x.trrprutrdcr Sccrion ,U.&PC l'{rhrrctson
<br />Dnler oRn.r:
<br />TYORKTRS' CONIPTNSAil(JN
<br />DIiCLAAAIIO!
<br />I hcrcby lfiirmundcr pcnalryorpdJuiyoN olrhc lollosnrr dcclnrrnNl
<br />-l
<br />hrlc aod will tuimain , ccdiicarc oi Co.snt ro Scll lnsuB Inr *ortcrs' .onlpc.qlion. .s ptr,ridcd rix bv S(rion :l7u) .r rh.
<br />trhor Codc, for rhc ,'crloimmc o{ rhc wuik for whkh rhc pcrmit k isqrcd.
<br />-lhrrcrn,lsilln[inrrinworkcFcoDpcnsalir'!in\urarcc.,\rdqundhySccrion:]XnofrhcLth.rC({!c.l'.rrhctdnmrnccolrlE *ork lbr uhkh rhN p.nnit is issuc{1. [l y s orts smpcnurtun insurlNc c!trin dl !.licy iumbcr !rc.
<br />('rtricr:-
<br />l\ri.lNu rbcr-Exlnc\
<br />Ic.ailirharirrhclErlornDn.cofrhctrorklm*hichrhi\Pcrnirisis$cd,Ishrllnrcmnl{iyrnyIknoninrfvaunncr
<br />v) trsb lxconr srhic.r ro rhc woikcn'.onrpcn$rnrn h* ofCalinmir. md ngtc thJ il I dn,old h..oDrc suhicr L, rh.
<br />*.rkd coDrt)risdrion trcvhions ofSccrion lT0Oofrh. Ldxr c(xlc.l shlll tunh$irh.o,nlly trilh lho{ I,R,vieuns
<br />WARNINC l'0ilure ro ecurc workcn .o rNnroliotr covcnac i\ rtrlawrrl. .trd shall suhjccr an..!nottr b.rininrl lrrrlis ind
<br />civil 6ncs uI loonc hutulrcd rhousrnJ dollars ($loo.Ut). in xddiri.n ro rhc cosr oi co'nPcn\rri.n. d.nnEs as Pr.v 'nrorrhcS.crin ll{)1a, .l r h. l.rhn C(xic, i' cr$t nlrrrortrcy l llcr
<br />*,",7^)6-1/
<br />Ihcrcby0mrnu.icrDcnahyolnrjuryrharl.mliencdundcrImvirinnorchaplcr9(co,nnttuingsithScclhn7tfl)).rDivhion-1
<br />dl rh. Busimssand Pofcsions Codc. md lnylic.nsc k nr fullir.c aMeftc.r
<br />/7/ 7
<br />7:%.12 ."^"*lyuz-0, (aat\
<br />cqx$!,ucr0NLENuNliic
<br />I h.rby dlrm un'lur [lcMlryorpcrj!ry rhd rhcrc h a.otrnnlclion knding rscky lo hc perlomuncc orrh. wolk lot *hich rhn Fnnir i\
<br />h$cdrsN..l09?, civ c )
<br />AIIIICAILDE1:I./TAA.IION
<br />I hcr$yrfll u cr pcnallyof perjuryon .rihc lollopin8dcclorarnn,s:
<br />I)cm)lirion Pd6nrAsh.sos Norificlrt'n F.d.ral RcSul iotrs al illc,(). P!n6)
<br />-R.quncd
<br />Lctrcr orNolincrlion
<br />-l
<br />ccniry lhll rhc t dcrdl rcgul.rions rcsudinE asbcdo\ r.frrval dc tror ErllicabL ro rhis flol.c'
<br />-l.eniryrhar
<br />I hrvc rcad this npplicarion and sr!r. rhar lhc Flc iniornurion hcorer' I agm lo ompl, wirh rll Cilv ard Colnlv
<br />orditutucs snd Srarc tjqs rclar i.g lo hilding .onnrudio.. ld hcrchy lurhori2c rcfl.scntarncs ofrhis Cn, and Coutrrv ro cnrcr u[,n rhc
<br />rhor. ni.flrrrl 0',)t)r'ry lnr r\l{.r,nr
<br />]1DIli(nnl or Agcnl Sisn.luto'/zz €ru rr *,.7^2r /g/
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framing 7:l , (g-i.rr&1 {)
<br />lnsulation/Enerqy
<br />Drywall 7"7 -/3u ')tSo-b v
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar ,.r/ - tD Dc.5a*&
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />FINAL 3.?,1-t8 J)cSzh ,fra)
<br />Certiticate ot Occupancy
<br />Notes, Remarks, Etc
<br />_l. as o*!cr .l rhc l)n,Fny. or nry cnrllolccs wilh wrgcs . hcn *nc c.nDcnsarion. wiil d. lhc s.rk ud rhc itodk n i.r
<br />ir[crxl.{ ur oflarcn $r slc (S.! ?(X4. Businc\s rid Pn,fcs\nrn\ C('dc: Tfic Clnfun(tr s Li.cnsc ltr* docr mt .pdy l. .r owtrs ol
<br />rhc pmFny qh.lbxildsor nnpnls th.n)n. nnd who J(rssuch*or[ hi'n\.ll orhcr\clforrhmulh hi\ or hq .wn cnrpl.].cs.
<br />rrvidcd rh r sucl inr,mrcnE.h.rc nol itrrctrdcd or oricrcd l'or slc ll hoN.rs. rhc huilding or impm\t'm i\ $l] *irhir ' c rtr
<br />ol$Dalcrhn. rhcOwncr tsuildcr *illh,vc rh.hunl.nofpn,virg rl ltorshc did nol huik.r nn[orc $c t'n]tErly lirlhcpurlxNc.i
<br />Erection Pads
<br />Flood Zone Certif .
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