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.l <br />BUILDING- INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BI'ILDER DEI,CARATI(}N <br />I hcr.by ilfinn hdcr !.nrhy ,,r pdjDry rh,r I rm cxcnDr rn)m rh. cotrlract,trs Liccnr ljw li,r rhc nnt,wine rc.$n (Scc.7(rJL5 <br />Busincsr rnd Piorcs{nr (rtc) Any City or Counl, shic[ rcquircs a pcnnir k, .on{tu.r. slrr. imProlc, dcnmlish o ePat an} <br />stru.ru.c. pri$ lo ns Nsurrcc. also rcquircslhc apflicanl in suchrcrmir i, filca ngncd s.'.n.nt rhir hcor shc is liccnscd Pursuanr <br />r. rh. Fovision\ ofrh. Co krcrtr s LiccnscJ kp (Cho c.9. C.nnrErcinS wirh Sccrion 7fi)0 ofDivniotr I ol rhc gusincs and <br />Pmlcsions Codc) or lhrr hC or shc h cxcryr lherctom d lhc bu\is ft,rhc rll.g.d.rcnrUnr AtryviolllionofscrhnT0:ll5hyrny <br />rprlicanr lor a prnnir subjmh rhc aptli.rnrb r.ivilp.nrlryornor nberhm ive hundrcd dollars(S50o) <br />-1. <br />$ oqncr of ihc Dmpcnr, (tr my cryk')tcs wirh wtrscs !s itun $b .omFnsrrion. will do ltE work odl rhc {tuiur h tur <br />inr.nd.d oroficr.d for srlc(Se 7(}1,1. Bnsirc$ Md Prclissions Codc IhcConta.tn\LiccnRtjwdesnor!pP!yloatro*ncrol <br />rhcpmFny wio builds or nniohs rhcB)n. nnd whu docs skh wo* hnns.ll or hcrslfor rhmulh hls or her owtr cmPloyccs, <br />proridcd rhar such inlmvenEnh arc nor iiicidcd or orcFd f(n sh li howcrcr. rtE huildi.s or iqnorcm n s,kl wilhrn m ytr <br />orlunpLrion. lhc Owhcr BuiLln sill h,n rhc hxlcn otrovine lhir hc or stu dii mr l{ild.r nr{ow <br />'h. r,$Fny for rne ,)llqrs ol <br />I. is.wn.r orrh. prlp.rry. ancxclu\ivclyconlradins uirh liccn$n c.nrr4nx ro.onnru.! rhc Pn)j..r lsLt. 7(44- Buiincs <br />n fioltsshnCodc'llrcCoirrlcrofsl-i.cnscl-awdocsnorapnlyk r.owhcrorpropcrtyrho build\or in,pro\ts rho.on. <br />rnd *ho .onrhcrs fd such pmtills wirhaConrmcto(9licc.scd Nslrtrr rorhcConrrrc(tr r l-ic.tr* t rw) <br />I rf,rrm untl.r S..ri <br />D.le: Orn€.: <br />WORKF'RS' C-OIVIPENSATI(IN <br />DE TIAAII9N <br />I hcrhy rlrrn undcr pcnrlry ofpcrjuryonc.flhu iollowiry dcclorrrions: <br />I hrv. tud will nri'r dir . Ccnrficric ol Consctrt h ScllhNur c litr worken d)mn i\dn . r( F)vnhd fff by Ssr ioo ]?m . r rhc <br />tibor Cod.. fr rhc p.rfonnd( ofrhc trork for which rhc prnnir is is{rcd. <br />!'in *utcr!.o r \rri,trr ln\uftn.r . as rcqtrndd by Sc.i ion ]TOO oi rhc 1lh0r Codc, r(tr rh. Frhrmxrc of <br />trs n r nruran.ccanici Md plicynufrhcrdc: <br />\c F,r^ a\C".i",,-] <br />1o c>j o\1 - 2or$ <br />I.cnily!hrr i', rhc p.narnhtud frhc w.rk nn shi.hrhrl Nr rir i( l$rcd.lshrlltror cmpbyrnt pcr\nr iriny nrnnci <br />n) nsr) h...nr \rhEd !'rhcworkcr.onDcnsrrion hw!otCrlilhrnir. r.d rgt.rh itI\hould h(otru {'hl.crttrht <br />workcr' .ompcnsrriontmvhion\ofSccrnn,:17(X)ofrhc lihtrCodr <br />$ARNIN(j lixilur k, \ocu( \orlr'\ ro rt)(n\rr!trr .rv. <br />ctr'l 6,.\ uf n) ono hutrd'rd rhotritrd dolhr\ lSllx).(Ixrl <br />S(tun l07b of lhc Libor C'Glc. tr crc(dnd <br />'"* -?lr'1 i?o1e^---T <br />-I tcrchy ufilrn undcr pcnalrrofFrjuty rhar Ln lic.n\.d undn lrovktun ofCh.nrcr, (connftn.ing wirh Sccrion 7000) ofl)ivision l <br />ol rhc Atrsincssatrd Pmtcsions Codc,3!d oyliccn\c is in tullror.c dcn rr <br />Ale 6 (O <br />1'^tl I o "'"yA <br />I h.rcby nfinm undcr |Enallyofpcrjurr rhrr rh&. is a c.nNdcrhtr lc.dir8.8cncy ror lhc F-rrbanan.c orrhc w.rk nr qhich lhis Pcflnir is <br />AITIIIANLDECIAEAIAN <br />I hcttry !fiinn undcr pcnrlly of p(ljury Dic or'hc r.0o*nr8 dc.larari.trs: <br />Dcmhion Pciints.As6.sros Notificlrion Fcdcrul R.$larin* lTirlc 40. Pan6) <br />-Rcquncd <br />t.lrcr ot Nolifrari,i <br />I.c 'fyrhd rhc fL'dcrrlr.Sulnrions lc3slinB xx rcnlrvxlxrc mr apdi.ibL tu this projccr <br />!g!r t'.omnly wnh ill Ciry !trd Coutrry <br />ivcs otrhirCi'y d Connlylo c cr!,x,nlh.-l <br />cdlriylhil I lnvc rcld l[n]pnli.rridr <br />:40J 1ts <br />Set Backs <br />Erection Pads <br />SLAB Floor <br />Subf loor/VenVlnsu lation <br />Rool Sheathing <br />Shear Wall <br />Framing <br />lnsu lation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Cefiif .+ /24/tz 5b6xlXw*aL *bq (tu ?h-5/s \<* <br />FINAL o/ll/ts 5D{.b <br />Certificate of Occupancy <br />Notes, Remarks, Etc <br />Forms/Steel/Holdowns <br />UFER Ground <br />T-Bar <br />issucd(sm .1097. civ c ) <br />n <br />!!,1i,'n\ rl sr,i.Ix\\ <br />rbovc mnt n,ncd ,,tupcny for <br />\pplirinr or,\xul Si[nnlurr:+Ni[GS