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SITE-WORK DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Erection Pads
<br />UFEB Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathing
<br />Shear Wall vu tJ/
<br />Framing
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />[/ aso n ry
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif.
<br />^\r-- i)f4'/8 t '-27-n ez.oYI-
<br />Certif icate ol Occupancy
<br />Notes, Remarks, Etc
<br />OWNER BU!LDER I}EI,CARATIoN
<br />I hcrchy alfirm under pcndry ()l perjlr, ihd I a dcngr imd rhc coNtlo6 Li(nsc Lrw lor rhc rirlkrsin! ra$n (s..70:ll 5
<br />Businc$ and P.ofc*bn Cd.): ny Cily .r Coutrry whkh rcqun i a Filnil k' onsrrucr, drcr. i:nfovc. d.nkrnh nr rclin any
<br />\h.lurc. prior lo its rsu{n.c. rko rcquircs lhc!pdi.!nr ior slchrcn.irk, nh a \igncd e.rcmllI rhd heor sic h licctrrd purulnr
<br />ro rhc F.virions.lrh. C.ntr.roas t-i.cnscd tiw (Cha c.9. Connnctrcing wilh Sccrion 7ffX) ofDivisn loirhc Busirrcs.nd
<br />Piorc$ionsCodc)or rhat hcorshc is cxetrul lh.rcriomand lhc hris tor rh. alkscd crcmo ion Anyvid,rionofScclion 70-ll5 t'y ony
<br />aprli.rtrr for r l)canil suhjcctslhc ap!liconr ro ocivilpcnalryotnol nDrc rhui fivc hrndrcddolld\ ($500).
<br />-1.
<br />!\ owncr of rh. lroIcny. o. fry .nDbyc6 wirh wn8.. a\ rlrir \olc .onr.nsai ion. $ill do ltNork lrxl rhc {mluc is mt
<br />i[cMcJ or oftcBd for slc (Se 7Or4, Busirrcs and ftofcsiors Codc 'I tr Cotrkr.ttr\ t-i.cn* kw docs nor lPplykr an o*Rr ol
<br />rhc pmr.ny who hdilih or iDImEs rhc@!. ari {ho dtrs sch *.rk hnn\clror hcr*lfor rhrcugh his or hcr owi cnfl.yccs,
<br />pturidcd rhur such inDorrEtrF .E tror i cnd&l or oalcrcd for qie lu ho*cvcr, rh. tuikln€ or n!,orcnr t hH airhin onc ,t(
<br />oiconDlcrion. rhc Owrcr Buiucr willhaw rh. hnhi.ftmving rl,tr lE or shc did tror huild or imfmn lhe lmFny for rrt pu[.$ ot
<br />La5owicrolrhcpmpcny.r'ncx.lusiv.lycoffr.rirewirhlrccnscdconrraci{nsroconnddrhePfl,F.r(S.c704i.Bu\iocir
<br />lnd thlissi.n Codc: 'l]lc Conuocrof\ Liccnsc ljs doc\ nor rppl) u Mown.r ol propcny *h,) huilds or i.rprovcs rhcrcotr.
<br />.nd wlb.ontd.hfnrsurinntccrswirhaCoNoclqs)liccnscdpursunrt,rh.Qrnt&rofsLic.n$tiw)
<br />I m crcmpr undcr Scclio
<br />uj)8.rE&5:rouruNirA:uo!
<br />DISAAAII!]N
<br />I rsrchy fllrni uidcr Nn,ht oiryju,yorc olrhc lollowire (l$lmriotr\l
<br />I hrvcri *ill'tui' rin n C.nir(-dc uf Con\cni k, Sclf-ln\urc lar $orkcra.ompcnsJln,n. r\ pn'vidctl Lr bySclihtr lrrx)olrhc
<br />l-lltin Orlc.l{n rhc p.norro.cc olrhc *ork f{tr ehth rh. Fnnir i\ N\ucd.
<br />I havc d *illmrinrrin sorkcrJ..nqrnsrrion insunn.c. rs rcqui.cd hySsriotr l7U)oirhc tihor Codc, lor lhc Pcrlonnnccof
<br />rhc w.rk tor whi.hrhN pcnnil is isnKl. M,wortcrs conrrcnsarion in\uEncc cmi.r dJrl lricy nunbcr c:
<br />PolLr Numhcr:
<br />-
<br />r,l',."
<br />-l
<br />ccnifylhlr in rhc |f,rlbr.hmc.frh. No flr whichrhi\r.nnir i( hsrcd. I c[(lltror cmnloyrtrypcnon inh! mrnmr
<br />n,isr)lr.o,rc{rhJ.drorhcworkcriconrp.osdionlrNofcllilb.nia-rndl8rcrhrriflshouldhc.onEsuhtcrrorhc
<br />workcr conrp.n\!riotrrrovisiotrsofS.cri, .l?(xr.frhc IifitrC{xlc.l \hrll. f(rrhqir[.on]|,
<br />s unlxslul nDA rhrll sth ( nn c lPblcr lo crimin!! |Enrlris trnd
<br />.ivil inc! xp k, onc hundrcd rhous0nd dollds ario.. d,mr8.s os ,)rovted lor lhe
<br />sc.rnnr.107601rlr l.nhr(lx]c, dcrc{ ud dn
<br />?.3 0.18
<br />t )t,t( t,AR,\l'ft)N
<br />I hcrchy ilUrn undcr rcm[yoipcrj$y I nicr |nov]st ofCl,qrrrrr)tcr trif, . ENirhScdi)n 7(x)i))ofl)ivisi{r.l
<br />of ihc Bu\itu\snid Pn,tu\siorr Codc, id myli.ctr\c i\ ir lull lor.crn clL.r
<br />r2 L
<br />r,"", 2'39:17 f
<br />I hcrch) rlftDurrcr p.nrlry otrqurylhrr I nding agcn.y lor rhc !.tonMncc oflhc sork f{rshi.hrht pc nir $
<br />n{rd rS.. rr)91. Civ C r
<br />A.TILI$NLIEEI.AXAIIOT
<br />I lEN6y Bfilnn uldcr pcnalry of!.rJLry on..frh. folh*nrs dc.l*rrnrs
<br />Dcnrlirion Pcmrih Ash.{os Norificarinn ltdcrulRcs!hrn,ns ( firl..l0. P&6)
<br />Rcquncn L. crolNoriricali.n
<br />fr,lc'nl rcgtrhrii \ rrsriin! xn{i!:r.ntrrilir. norqrpLi.rhld n) rhi\ t'(!c.r
<br />/K;"'s corcd I 0Fcc ro Nmply wirn ,ll Ciry und Coutrry
<br />r.prcsc alivcs ofinh City lnd Co!.ryrorme, ug,nrri
<br />-,.1-30.1tr
<br />BUILDING. INSPECTOR RECORD
<br />Forms/Steel/Holdowns
<br />Pool Fence
<br />FINAL
<br />v
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