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BUILDING. INSPECTOH RECORD
<br />SITE.WOHK DATE ID/SIG.COMMENTS OWNER BUtT,DER OELC I'{TION
<br />I hcr.by affirm hder Fntrhy .r p.rjury rhar I um cx.nu rio'r rhc (.onInclos Ltcne Ln* for lhe folk,win8 fu$r (S{ 7031 5
<br />Bu\n$r and Bolc\{otr Codc) Atry Cily or Coutrry wnich r.quircs r lemrir ro con(ocr, ,hcr. imflok. dcfrrish or rulon any
<br />(rucluE. prior lo ns nsuancc. aho lcqntcsrhc arplicanr r'or such pcrnir b filc r siSncd qdcnr lhal h..r \hc i\ li..n$d Pu^udnr
<br />r' rh. p.v^n,ni.rrrr conra.br's Liccnscd L{s (Chifrcr 9. Commercnrs $nh S\-rtr. Ttxt) .r Dilh'on I oi lhc Businc* and
<br />Pn a$tnrs CtJdc) or lhrt hc or shc t crcm, thclclromlnd rhc bash lor lhc allcscd cr.mprion. AnyviolalionofscdionT0.ll5hyany
<br />{tlicoDr tor o pcflnit subjcch rhe arplicalr loacililpenrlyoinor )ftrhatr nvc hundrcd dollars (5500).
<br />I. as owffi ofrh. Eo|Eny. or flry enrtloyes wirh w.Scr.s thci! v,lc confcnerion. willdo rh. sork.rt rhc sirxrurc is mr
<br />iDrcBlcd ororlcrc{l lor qk (SK 7(M4, Brsincssund Pmrcsions C.d.: ThcCoMactols Liccnsc Llu docs nor apply ro owncrol
<br />rlr pmndy wlx) burlds or hpmres tlLmn. nxl sho des such sorl( hinscllor hc^clf.r rlrough his or hcr o*n cnrlL,yccs.
<br />trcvid.d rhar su.h inlltuwmnr e m( idcndcd or offftn fo. sL li howc\ cL rhe blildin! .r i protftnr k $ld withtu ntrc ,! r
<br />olcompkrioi- rhc o*os BuaHd will hrw r]I burdcn dr proving rhd hc oi sh. did ml build or improk rhc pmr.ny ror rtr ttr(Ds of
<br />I. N ostur of rhc pn,prn y, am cx.lu\ rvcly .ontrlina qirh li.cn*d conrmcn's ro cotr{dcr rlt ,rmjN (Sc. 7U1,1. trusncs
<br />uxl PDli:\tbn Colc lhcCotrrrsctr'sl-i.cn\cl-rwdtusnorrpplyt'nnowmrof|}oi'c y*h. huildsor imtrcvc\ rltcrcon.
<br />rnd who.o.rrd(lnrruchtnojccts*irhaornlnclo(9li.crNcd,'u6uanrbrhcG'ntDcror'rL{.nscLrw).
<br />lr cxc llnu $sc.rn .lJ.&l'.C lnrlhi\rcr(tr,
<br />DrIr: oen€.
<br />woR(ERS CONIPFNSA',TI{lN
<br />DICLAAAUON
<br />I h.rby nllirnundft ,.ndlryorpcrjuryonc otrhc followin8 dNhldions:
<br />-lhrvcudsilltui
<br />rih d Ccdin. c or c.rsc to s.lr- rNurc nn workdl conrpcns ion.as pruvidcd r(rbysccri(,n1700oflhc
<br />tibor Codc. for thc pcrlbrmn.c oI rhr sork Io. which rht Pcrnir n i$u.d.
<br />I hrrc and willnrinnrii q.rkcn comEn{aliotr insuruncc. rr rcqutcd hrScrri.i lTm.frhc t:b.rCodc.lottu Pcrlnrnuic.of
<br />rhc work tu whi.h rhilpcnnir rIl trlcn con,Fn\rri{,, i'Nrri.c.rflcr d |Flicy numbcrarc
<br />2
<br />-l
<br />ccniiyrhrr inlhc pertormrnlrorrhc work rur shihrhis n i,nil is issu.d.l shall nol empLy un, ,.n.n in atrymnnnc.
<br />$ ,\ k, h.cdm suhJ.cr ro rhc sodcr' ompcnsalbn laws ol Clliiorni!. lnd ,Etd rhar if I should bcc.m sublccr lo rtr
<br />porkcs .otrrp.trsrlior pmvisionsofScdion 3?(norrhc tit rCod..l rhill. r.nhwirh.Tmnl
<br />WARNINC: Failure Io rcur s.rk rJ.omr.nsarion.ovcEgc ir unhwtul. Md shall su cmpk,y.r h dniFlFnallic\ und
<br />i.n, danuscs as prusidcd tur thccivil firc\ !F b ofc hu drcJ rhousrnd d.lhn (lltu.(Xx)). ir .drlirl.r ro rhc co( ot:;:JE;{ff pprionr:)a
<br />Ltlli:t-t !_(tlrrB,l(108
<br />I hcrcby 0lrteundcr |Enallyotp.rju.y rha' I no licctrEd rdrr provisi(,n drchl,)rLr 9{
<br />uf rhc atrsincsr rnd Piolcs\ions CoJc. and my licctrsc ir ir lullnncc !trdcfiocr
<br />ng I l, Sc.rrr' 71)li)) ol l)'v^t r
<br />l-./l-)dru@.""*-*
<br />I ficEhy om.rn lndcr p€natry of Friu.y thdr rhdc n a mnshcrion bndinS agcmy lor
<br />nsu.d (Scc 109?. Civ C.).
<br />orihc work lorwhichlhhrc.mir h
<br />AIIUCANI.IIECIIIAAIION
<br />I ltrcby !n'nundc! rcnally olDcrjty onc olrhc follo*inE da.'!{!li,,n{
<br />Dcnsliri.n Pcnnirs Asb.sros Norficdioo Fnerll Rc8uhlions (TilE 40- Prn6)
<br />Rcqun.d Lncr of Nolilicolion
<br />_l ccllifyrhar rhc tcdernl tosuhtion\ rcgd'lire a\bcsros rr.tuvll uc nor iJ,Ili.lblc t' rhis prujk
<br />I ccnily rhnr I tu*rcadthis oplicalionona{ crhar I i',n)nn i(,r n.ortccr Irlre!)c.nrtly\irhrllCiry trl Cou rv
<br />ordiMnccs rnd Sr.tc Lrws Elllins ro buiBinscon(rucr , rorlxtrizc rcprcscNnlivcs ofthis Ciryand Cornry r
<br />abv. mnrnnlcd pmFnrfor insFsrion pu{rscs.
<br />apprienr or Asenr sismrurc K Dole
<br />ru.(,,*,,,,"" "*"",un,,X-.
<br />U
<br />\17
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loorivenVlnsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lvlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Qertif.//? zZz- /LJ,./DZ**-, /.?. /,Do/zr II
<br />FINAL /"Yu t
<br />Certilicate of Occupancy
<br />Notes, Remarks, Etc.
<br />.t
<br />I .M.''.
<br />^lJr$
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