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BUILDING- INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS OWNER BU!LDER DELC R"4TION
<br />Ih.rcbyaflirf,und.'F.dlryofp.rjuryrh l m crcn,/ lrom rhc C{,nr,.bn t-icc.* Irw for ih. folk,wirB n.on(Sc.70ll5
<br />Busincs and qolc$ion Codc): Any City or Counry which r.qurcs r ncorir ro conslnrct. ilrcr. imnrovc. dcmlih nr rcr'n rny
<br />qtu.rufu, t'i, t, iri is\lance. aLso Eqrncsrhe amlicanr ior suchpcnnirro filc a skncd natetunr rhar h.or\h. i{ li..nscd pxrsuMr
<br />io rhc prevni.n\ ol rh. Co.tr.ct.is Licctrscd tav (Chrrr$ 9. Com'rencnr8 wnh Sc.rn,n 7ftx| of Oiltnrn I oi rhe Blsincs and
<br />PnrlcsioNCodc)orrhrlh.or\hc is cxcnrfl rhcrlrom and thc b.sh lor rhcalkScdcxcmplion AnyviolelimotSc.rionT0.ll5hy,n,
<br />,mli.arrorar.nni,suhjerrh.amli.rnrbacivilpcnrlryolnotnuclhrntivchuidrcdrtolk(\(S5u))
<br />-1.aso{nc!oilhepmpcny.(trnrychployeswirhwrycsrsrhcnshcomncnrorion.Nilldorhcw.rkm
<br />lncnodurcho,
<br />i cnLd oroficrd for !rl. (S( 704,t. Brsift$and Ptrrtsio.\ Codo'fh. Conrrcrol\ Li...s. L,s docs nor apply r. nn o\ ftr .f
<br />rhcrarrny who hrildl or inwows rhcNn. !n! wh) d,rs slch \)lk lrinNclfo. hcaclf.r rlmugh hr\ or hcr owncnrrl,Drcs.
<br />prov cd ltur such inuroErrcnrs e nor irncNLd n orcErl for srl. lI h.scv.r. rlr ${i[]iu or inDft,v.nBnr h \old {irhh .trc yqr
<br />ol conphton. th. O$Nr Buikl$ will hrvc r,r burd.n uf rrovinB rhd hc or sh. did nor build or imfiold rhc pnrdy for rtE pulb* .f
<br />L rs owncr ol rhc l,l)pcny. ruc(clusivclyconrmcrirg wirh li.ctr$rl .onrrrorl ro conrrDd rhc t)mjcd (Scc 7O&. Bu\irc\\
<br />lnl IbLssir Codc Th. cotrra.rf's Lic.nsc ljw d,rs tr.r lpply r, an .u n.r of fi.p. y wh. hoild\ or rnll)rovc\ rhclcon.
<br />r.d who conrEck l'or cuch pnrccrs wnh a G)nrrldon, lieflscd pur{rnrr' rhc Conrrocrois l-iccnsc lj+r
<br />I anrcrcnrpr udcr Sccrir)
<br />t,t" - -1 24 v f
<br />I hc'rhyxlTi'n'und[ rc xlrrol r)r4triyoDcol r[. n'lL,trrinE (lc.Irnrtnx
<br />-lhlvc
<br />ud sillmainlair aCcnificolcofConscnt roSclf-lnsurc for workcr' ompcn$lior. as nmvicd nn hy Ssri{,n l7(x)or'hc
<br />Llbnr Cdc- torrhcpc onmrcc ollhcwork f.r whichrh. ldnrit h ssu.
<br />I l'r!c rn,t *illmi'rrrin {ork.( comp.n\di{,n iniurrncc. rs rcquircd bySccrhn.lTlX)oIrhc I rhorCodr. aorrhr fr onun(of
<br />rhc qork f.rwhlch rhn r^--irnir i{ ir\ud. Myqorkcrs ro'npctr\rf.n insurrncccrricr [nicy fu ,hcrr.:
<br />Poli.yNutrrtjr Expncs
<br />lccnili ihri in rhc pcrf.rnumc(n rhc work lbr *hich rhi\ n flnil i\ i\\u.d.l shrllnoi cnrployrn) p.^.n inrn, trwrtrcr
<br />s rlr,hccoDr suhjccl bihc wnrkcr cotrrfctrsdn lrwsolcrlifir ir. Md d!rcc rlrd ifl\['uI] tN.rnc qrbjcd ronr
<br />sorkcr\ conrNn\arion l)n,vhioos oiSccrio lTu).lrhc rjtsr Gxlc.l shrll liJnh*nh.oDlrly $ith rhor Drornion\
<br />\YARNING: F.ihrc k, *rtrr. wo.kcr(.ontP.n\rri,,n cove gr i\ rtrh*ful, rnd \hall ruhJc.r r'r. rtno)tr h ninnnrl |).n^lrcs ind
<br />sc.rn l)160lrhc lrlrtr (i c. n.rc{ rtrrl o
<br />*
<br />I h.Ehy sffirnrundcr pcnnllyoipcrjury rh(l I rn llcctrs.d utritcr ptr,vki( orCh(flq9lco,nrmncirEsnhScdion70(x)rolDivisnrn:l
<br />ol lhc Busir*$rnd Pn,fcssion\ Codc. iM hyli.ctrs is h rullfomddclncr
<br />Conlroctor:
<br />c!) sta!']qIIoN.LEBDINCilil:lCr
<br />n\ucd (Scc log7. Civ ( )
<br />IPILIEANLD}:CI.A8A.1IQN
<br />I ltNr,y0ninnu cr pcnrlry ofl].rjry onc ollhc f.lbwin8 dL\hrittff:
<br />Dcnmlirion Pc nir!Ash.sos Norifi.rri.n F.dcralRc3trlaridr\ ( rirb 40. Pf6)
<br />-Rcquhn
<br />l!ncrol Norifca'ion
<br />I ccniftrh rh. Ld.alrclllnrions ns&ling aihc{os rc br"ldr. noranpli.$l.r. rhis pml.cr
<br />><l ced ily rhar I havc rc l rhh amlEariotr aM shrc rhar rhc .brc inlirirn^l,on is conccr I r8re ro comply wir h ! ll cir y rnd cotrnry
<br />dJinx r..\.trrrs1xt t,r\ ! r.h1 I hcrcbyrtrrhori-..rrcscnlrlivcs oflhis Cily and Counr, k) ctrrcr tr|r.n rh:
<br />aMvc ff,nri{nrd |n.ncnv l]""1rr-P'
<br />*o-/1-P.*(*-^"(pn.r), D( Le\l'1 B ^,", ;1 Z.l4
<br />Set Backs
<br />Formsi Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />l\,4 aso n ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Qeputy Final Report
<br />Engineer Final Report
<br />FINAL 4,L1 - lt J/rJD\l'1Y
<br />Occupancy
<br />Notes Remarks Etc
<br />,.|
<br />SITE.WORK
<br />Flood Zone Certif .
<br />Certif icate ot
<br />I
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