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BUILDING. INSPECTOR RECOHD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUII,DFJR DI]LCNII TION
<br />I hcrcby rflirD uDdcr pcnrlry oI Frjury rhal I rm.x.'tfl ftnn rhc Conri.cl.s t-icensc li* n,rht rrnhqir8 rcasn (Scc7).ll5
<br />Ilusircss ind ltoli$ioo Cod.): Ant ciry or Coudy qhi.h rc{tuircs ! pen.ir b <on{ru.r. alrcr. nnPtovc. d.molnh or rp atr!
<br />lrd.turc, prnn r) irs hsuoncc. {ko rcqut s rhc ardi.Mr tor su.h p.mnt ro ih. siancn nalcmtrl rh,r h.or shc h liccNed I'uisu0nr
<br />ro rhc rorkion\ of rh. C.nlh.lois Liden$d Lrw (Chaprcr 9. Conhcn.in8 sirh Sccron 7000 o{ l)ivhbn .l ofrhc Businc$ ,nd
<br />Pn,f.\\n,n\Codc)orrh.thcorrhciscxcmpllhc.ciroDtrndrhcllsisntrrhc.llc3cdcxcntPrion Anrvn,hrionofSc.tionT03l 5hylny
<br />anplicanr Lr r pcrnir \ut'jc.k ihc trrflicd r tu acivil|ttrlltyolnot Drrc rhan filc hunddd dollds ($5(x,
<br />l. ns owncr of thc prcpcny- or n,y .npl,Des wnh wn8c$s rhcir $lc c. lncnsrrn,n. *ill do rhc *ort ox] rhc (Mrure is mr
<br />irlcrd.d or ofllred ror sl. (Se.7O44. atrsnEss nnd Pmltsions C{'d. Th. G,nt..tois l-iccnsc l,a* does noramlv ro an o$nerol
<br />rlr pnipdr, who butus or nnpmvcs rh.6n. d qho &$ ruch $* hi.,sclf or hc^clf or rhmu8h hh ot h.r ow c tpk,vccs.
<br />provid.d rhar ru.h i'nrn,Emnh orc mr intnd.n or ollcrcd for sk ll. ho*ctr. lhc bliui'rg or i'nPn,v.m h soH wirhin "nc Jtr
<br />o! conDlcrirn- rhc Owmr Builld *ill hrvc rhc budcn offovin8 rhd hc or shr did R taild.r i,rrmvc lhc Pmpcny aor rhc tuli{ of
<br />I. o*krofrh.rhlcny.!trrcxclu\ivcly.ontx.ri'rsRnhliccn{dcoorro.trbconnd.rrh.ptujccrlscc 7l!l4.Ilu\inc!\
<br />iln thrbst,nCodc'rhrConrrktrsLiccnsct-0$doc\rolrl]plrroanosn$.lfn)ncnyuhohlikllori'nt(,vcsrhcrcon-
<br />did trho.onndrtursuchprojNn$irnnContrkn(nli.ri\cdrursunlbrheC.nrEckns!-i..r.lr*)
<br />I Jn.rc'hDr undc' sclron .B &PC narhF'r^on
<br />jllrEsEeEl&[r[ENSAIlaN
<br />DECIABAUA!
<br />I hcrcby.ffinn under p.nllry or pcrjurr.nc orrhc rollosinS dcclffdions:
<br />lhrlc Md willnrdrir rCenificalcolConscnr b Sclf lrNtrc fitr s.rkc(dnnPcn\lliln,. Js l(,vnhd turhr_Sccrion.l70l)ofrhc
<br />LnborG c. forrhcI[ rodakcolrhc sor* forshichrhc pcnnir n $ucd
<br />I havc and will
<br />'minrair
<br />aort€ra compc.snlion inlurnn c. ss rcquncd ny Scd id :r70o or rh. Lator Codc- td rh. pcrlormmc of
<br />lhc work for vhich rhhFrmit is issu.d. My*.tkcs smPcfls.tion inslrmcc.didrufir po[c] numb.r uc
<br />CaEier
<br />-
<br />Pol,cvNumh.r-
<br />I..nifyrhdrirrhcpcrlolunceofihcworkf{trslrichrhNN nil it is$.d.I shrll ior .mPbt any lrr\oo inrnt 'nntrmrs s ro h(dnrr s!l'J!d tu rh. workcn' comrn{l ion hss ol Crlii(trtrir. rid a8rcc ih ilIslould s.cont tuhE.r rorhc
<br />$orkcs conrFNrri(,n pnJviriotr\olSdion 37($ oflhe lrhnr coilc.I \hrll.lirilhqirh con]Pl, *ilh rho{ rorhio.s
<br />WARNIN(;] Frilurc Io scurc *o.kc6 compcnsrtn .ovcrrtc i\ unhulul. rod rhrll srhiNr an ctnnloycr ro sihinrl Pctrrkics dnd
<br />cilil ftr( ut t(' !nc hunLlrcd rhousnnd .lollr\irnr nr rh. co{ of co p.is nr, drnE8cs as pnJvitlcd f,tr rlt
<br />S(ii,)i :1076 ofihc Iahtr Codc. inrcrcn and 6yr,-L.s"*. - 7/Zr._/lX /L2k-
<br />DEI]I.ASdIIQN
<br />I heEhy amrm undcr pcn.lryofp.rjury thol I afl licctr*d undci pmvi\n,n orCh.lrs 9tco.nmncins wirh sd'ion 7000) ofDivhknr:l
<br />ol rh. Busirc$ ond Profcssion\ Cst , ard my li.cn$ ir in tull fore ann eflr.'r
<br />N
<br />'k,tfl1
<br />c rQt<&"4,t;j-
<br />CONS]'RI]C'I'!oN I IINDIN(; AGENCY
<br />I hdRby rfln uMcrpcnrlr,olFrjuryrhriittr.ir1.oqn.!iotrkndir8r8crcyinrhcrrf.rnr.nccoflhcslrklarwhi.hlhislErnriris
<br />i\skd iScc l(197. Ci!. C.)
<br />AIILrc/U{LDECI,AAAUON
<br />I ltnny rfirfl rndcr nnrxy ol r.rjury onc otlhc ftnbwins d(lmrn,n\:
<br />Deayniion Pcrmik Asbcnos Ndrifi.dion I'cdcril Rc8ul ion\ fl ib.r), Pt$)
<br />Rd!unctl Lc(rrr ol Norilicnrhtr
<br />I.crrilirh i lhclcdcnlrcgulllt,N rcg di|C,\h.sros rcnNvalrt norrrnli.rhlc t,rhi pbj$t
<br />i.rriotrand srarc rhar rhc rh$c i',lon i,)n N (orccr I aarerocon,!lywirhall Cilyrnd CouDry
<br />huildin8 co.nrucrirn. and hcrdr- rh.ri7.rclrsctrrrrirsolrhiscnyotrdCounryro.nrcrxNnrh.
<br />l.cnil! rhrr I hi\r rud rhn JnDI
<br />*,r.J**,",1 S"" r,*. "r,,r"l.,c nrmmncd nmncn) rff m.r*Ir
<br />^DDrkonr
<br />m
<br />^!enr
<br />srsM'uEZ
<br />," r*^ ^"rOn^U.Z /4.-9P 244 1/46
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Subf loor/Venl/lnsulation
<br />Roof Sheathinq
<br />Shear Wall A
<br />Framinq 1-10-lt k.W'td
<br />ln s u lation/E nergy
<br />Drywall
<br />Brown Coat
<br />[/lasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certil
<br />FINAL i-70"g vt+rLl
<br />Certilicate of Occupancv
<br />Notes, Remarks, Etc.
<br />UFER Ground
<br />Ext./lnt. Lath
<br />tt
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