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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUII,DER DELCARATION
<br />I hcrchy rflirm uRLr p.nalry (,1 Frjury rhar I m c!.mfl lNnr lhc Conrra.k,6' Liccn€ Law tn rh. toll)win8 rcasrn (S.c 70.11 5,
<br />Bu<in.r\ dntl Proltlsi('n C{il.): Aiy C y nr Counry Nh(h rcqu(! I Famir l. conntud. ,lrcr' im[ovc. &rutsn ot rcran sv
<br />nE.rurc. pri{t \ Nurncc,.ko EquiEs rhc apdicam n, \uchIEm b lilc a ngncd srarcNnl rharhLor rhc 6liccnscd PuRBnr '
<br />h rhc imvisions oa rtE Conr&ntri Licn$n Law (Chrprcr I conrnEn.ins *irh S.crn)n 70fi) oi Divisbn I or rh' Busincs sntl
<br />Pn,aesnrns Corlc) or rhnl h.orshc iscxcmrr rhcrcaonr ind rhch.sk nnih. dlcC.d c\cmPrh. AnyvnndtunolSe.rion?0.rl5bva.v
<br />rptlic,mbrrpcnrilsubjcc(rh.,Itlic,nrloa.ivil,,en,ltyolnornor.rhmlivc[trnJrcddollds($500)
<br />t. as own rofthc pn)lEay, ormy cmtlortcs wnh w4cs rs rhctr nnc comn n\ on. w ldo rhc $or* d rb.stBlris('
<br />i'n.,rLd oroflard lor s0lc (Stu,7044. Busnlc$ anJ Pnrtsion\ ci,'lc Ihc O)nrn ttr r Lic.nsc Laq docs nolaPPIy u,n owncrol
<br />rhcnoFny wk) buildr.r mF)vcs rhs$n, r wlkrdocs$(hsi.himsclforhcrcliorrhnrahhisorhciow.cmplovecs,
<br />tlnrvidsl rhorsuch ihpn,voknls c mr int.n'.l.rl oroll'cFJ ntrak.Il k'wcvcr rhc htikli4 r lnlp$vcm.r k $ld Rthlr orc ,cs
<br />ofcomnbrbn, rhcoqncrBli cr win havc rhc bulen ol pn'vins lh,r h. d st* dil fr, IDiLl or iriptu!. 0r lNFnv lnr rh. puqDc ot
<br />I. asowncrol rhclFlo.dy. afrcxcl$ivcly.onrrr.rit,8 wirh li(.scJ e. r&106 ro Lonnrud rh Pn)lcd (Scc 1044. Busincs
<br />a'J l\uld\aE Crd.: Thc Coarr"cktr r Li.cnsc I-aw dlrs lor,nply k, d uwn$ ol nRrPcn, wh() hu'lds.r mptor.s rhcron
<br />and *l& cootrcGlar suchpojecr\ wirh a conra.k,1, li.cnsq.r puru,nr ro rhc c.nlri.tn \ Liccn{ tiw)
<br />I n.rnrtr ttrJ.r Sc(lr)
<br />uaS6rrEgcolllENs rl9l!
<br />DDCLAAAIIQN
<br />I llcrhy rflinn unJcr t'ctralry ol ncrjryon..l rhc l,nb*rr Jc.hnri,,n\:
<br />I hrv. .rlCv,ll md.m a Ccn 'trarc ur Co.scd k Sclrlnslrc hr wo (cr' ompensarn,n. as pNvklc,l for ty S*rion l70O ol rhc
<br />Lrhtr Cr, ,d rrE ocn,'llrmr or rhr h* lor *htrh rhc nm a n.ucJ
<br />X** "",.r
<br />.
<br />'rr
<br />.,.-. ,-kci\ .omrEn.,ri'n uNBfr.. ,r rcqurcJ hy Sccrnri l?00 ol rhc L.hor CdJc. ror rhc Frfo.rmt' ol
<br />rh. krk tur whtr'h rhn ncm '( trsuAl. M, w"' r.F' n,mlcnkr
<br />'uh 'n'utdf,. lr'.' rktlolrynumh"r m'
<br />1ft^er,l !-, 't
<br />L -)A--L)
<br />-l
<br />ccn,ly rhrr ii ihc tl(rlornFmc ofrhc work lor whrch rhis ocnlir i\ nsucd. I shrll nor cn{,loy any Pcson in any nmncr
<br />$ ,stoh,.onr sltFrri, rh. wolkc^ d)mpensriion llws of Cdlin'mia. d aamc ihdr ifI should hc!)nE vhicd rorlr
<br />workcc'qnrpcnBrionpn'vrn,ns.fS$ri.nl?0Oofrh.tjlttrC' c.I sh l, tunh*ih conrdy wrrh rhoe Srvi$ons
<br />WARNINC F.rlurc lo E...urc *ttrk.N u'mpcnsartr,n.on'aIc,s unlrwtul. atulrhlll subiccr an mpl()vc, b.rininil |].mllEs rnd
<br />.iv,l lincs np ro om hunJeJ rhourinn noll.s (Sl 'n J !r kr rhc .on ot ro \rn\rltru 'hro8cr ds l]rovilcn lq rlr
<br />s.d dn 1076 o, rhc llhr CRl.. st.rc$ inJ anr
<br />o.r", l- lv-1,
<br />![cr.68arlo!
<br />I rfrbyafltrnu c{EnrllroIl.rjuy lhal I m liucnv,l unncr ptuvhion orCh.Prcr1) (commNins wirh Sccrirn 7000) 'fDivisnrn ll
<br />of rh. Ausmc$ Mi Pnnt$ions CoJc, ,rxl my ltrcnsc is in tull lnr.c iJtl ctlel.
<br />L-ll oi r"*1
<br />[- rq--u,
<br />gqISI8IqIIONTEN TIG.AG.EIII
<br />I hcrchy allirmunJ.! Fnrhy.l ncrjury that rhcre n aconntucrion kBlilr! agcnty tnr rhc n dnmNc olth. w(,rk lot wli'h rhG Fmn rs
<br />L\{trJ rS.. l(}97. (iv (.)
<br />IIILICANLDECIAS{IIAN
<br />I h.cby afm un l.r p.ni[ y or pcrjury ore or rhc rolbwmg del(.l bns:
<br />D.mhion Pcrm s^rhcso* Noliii.rli,in Fede&l Rcsourn,nr lTnlc 40, Pan6)
<br />Reluircd kncr or Non,i.rlm
<br />t cci(fv rhor rhc tiarcrslrEJLrlns Ec.rJmp .\h.Jr\ rntr'v,l 6rc n.r iPll(u hL t" rhqruFLr
<br />-/.r.alcn'fyrh,rIhrvcr.adrhsinnlE Fn aal {ar. rhd rhc rh)vc inlbrmarion i clmcr I asN lo oopl, wilh all Cirv and Cou.lv
<br />;!in!n.!s d.l Srarc L.ws El,l iri lo huilding omtru ion. .d hercby aurhdrix tcPrcsntalivcs ot lhh Cilv and Counlv ro cnrr uron ltE
<br />abovc nrctrlinr.,l nn)r^-dt lar trN
<br />Appli.anl or A!0t Si8.nn,e l- iQ -t:
<br />SeI BaCKS
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framinq
<br />lns u lation/ En erg y
<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 Certil.
<br />F|NAL / /.4/ lJhkl ELfdL /oLl
<br />G;tiEaate6abcduparrcy
<br />Notes, Remarks, Etc
<br />Erection Pads
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