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BUILDING. INSPECTOR RECORD
<br />oWNER AUII,DER DEI-('ARATION
<br />I hcrcby nfim uftlcr pcn0lty ol lcrjury rlu I rcxcmfl in D rhc (hnrtrctoN t-iccnrc Lrw r'o! rhc n,lk,win8 rclw,o lscc.7o:ll5
<br />Busirc$ rnd Protsn,n Codc) Any Ciry or County whi.h rcquncs r lEmri, ro cnnnrucr. rlrcr. iryrolc. ddm.li\h ot dtJn mt
<br />rru.turc.lriorIo ns hsum.c. ako rcquircs rhc {'rlicd for such |Enit lo filca \isncd daremnl rhllhcor\hc ! liccn\.d IUNM|
<br />b ihr pmvhnns ol rhc Coitrr.ror's l-i.ch*d l-r* (Chaprer 9. C.m'n.n.in8 wirh Sccriotr 70OO .l Divniotr I ol thc Au\iDc\\ rnd
<br />Pftnt$ionsConc)orrhrlhe.rsh. ncxcnrpr rhcrcfr nri rhc bisis lor lhc lllc8c(l crcDrrri,,n Any lidarion or s(ri 70rl.5hyai,
<br />rrplicrnr fin n pcnnir \rhjdr\rhc trprli.rirt, acivilp.nrlryolnor xtr drnfiv.hxndrcddollnn(S5m)
<br />-l-
<br />0s ovncr oa l hc pmpcny. or m, cmplorrs wirh *aScs !s i heir elc comrcnsrr ion. will do rhc *ork rnl dr iturn is to{
<br />i'nc,rld or oflcred lff slc i Sd 7(}t4. Bu:incs dd Pmfc\\n,nr C.dd Th. C.dtr.tor's Liccnsc Ij! dNs trot rprly h ,n oenc' ol'
<br />rhcpd)Eny who huildsor imrmvcs lhcmn. onl who der such soli hnnscllrr hcrEllor rhrrsn hi or hcr own cnltloy.cs.
<br />pr.vidcd rhtrr srch inpi(,vc'rnh m nor inrcnd.{ Dr oficrsl r'or s,. li ho{cvs, rL bxildine or inro\tm r is s'ld qirhir onc rtr"
<br />ofcotrDlelion.lhcOwncr Dlihcr willhlvc thr ludcn ofpmvins lhal tu or shc did trol build o. nnpmt d'c ln,Fly rot ftc pu$x,$or
<br />l- r\owrc.ofrhclrr(rcrry. smcxclusivclycodrrdin! wirh licenscdro.t kxk,conrnr.rrrrp'oJ.\l(scc 704,{. tru\ine\\
<br />xl ai)fr*sbtr Cod.:1hr Cu ta.tn r Liccns. Lrw dd\ nor rtplyro MoFtrcrolprolEny$k) huildsor in,provc\ dtrc!tr,
<br />and sho cotrrrrrs tur slch nnrcc( *irh ! Conracro(n liccnscd pu^ornrt,rhcCunrrckr'\ Lirc.\c l. q)
<br />I !ncxcDrpr undcr Sr..tnnr
<br />Oen.r:
<br />woRx FRs' c()t!tFltNsATrr lN
<br />IlEl;l,I3AIlON
<br />I h.r.by allirfr !n.l.r p!nrilyoipcrjury oN olrtu tulbwinE dRlirrri{'n\
<br />-l
<br />hrvc od will mrinbin r Ceaificrrc ol Conscnr rosclfln\ure i, sorkc.i.onlFn\driotr.,1 providcd lnrbyScdtn lT{x)oilh.
<br />ljnorCodc,r'orrhcpcriormrnccotlhcworkn,shichrhcpcnnil nisucd
<br />I hnv. r d will 'nainrri wo&$a comtlcn\drion nr\ufunrc. d\ r.quitu{ by Sccr i(in .1700 of rhc lnhtr Codc. ir rhc Nrronui.c of
<br />rh. work ntr whi.hthh Nnn[ is is\ucd My Rorkcs' .o Nneriotr nr{tr0ncccmE nRlnolicynumh.rur
<br />-l
<br />ccailylhnr ir lhc l}crfonBrc or'rnc wort rbr shich lhh Drrnir is h\ud.l rh,llnor cnrrk,yany pcrson ir onymrnnct
<br />{, dr tu b...m \uhl..r b rh. sorrc corhp.trsrti,,n laws orcnlironri,. nM rgc h ill \hould nccom suhjd rortr
<br />$(trkc*..mFnsdnrprolisLotrsols..rion:l?({)ofrhcbhnctdc,lshrll.lnnhwirhcomplywirhiho{provi\n,n\
<br />WARNINC t'nilur h rccurc wotkcn coq*.s.rion .ovcn-!c is unhnful. d shlll suhFcr an.mrl,rr ro dnninal tcnihas !trd
<br />(ivil incs up b onc huturcd rhous{nd dolt s ($loo.t)(tr)
<br />SNrion 1076.llhc tihor Codc. inlcrcsr aM 0it my\fccs.
<br />irnnr to rhe co( oiconrensalion, drro8.s ns povidcd lor lhc
<br />8:^ ?
<br />IEQAAAIIAN
<br />Ihcrchyirni,nurdcr pcmlryotrerjuryrhai I !m listrscdundcr pmlisi,D oi Ch{rcr 9 lc.nn1ti.i'i8 sirh sc.ri 7(xr))nlDivisi,rl
<br />fl rh. llu\i',c$ r Pn)ns(nN Codr. tr (l n\ lnc N i\ nr 27 ?B/ (7U
<br />x
<br />coxErxuquu{rENDtNliltiENcr
<br />I h.ebrarfirdu.dcrp.illryorFrju.yrhor rhm isacd.irucrion Ltrdin8 ,Bcnc y lor l hc lerforronce of l nc $ork torwhichlhiar&mir h
<br />hsuc.l(Scc.:llj97, Ci! C ).
<br />Lxnd{ ' NJnrc
<br />-
<br />d}IUCANLDECLAAAIION
<br />I hctrt y trfiinn utrdcr ,)cntrlry ol tcrjury one ofrh. followin8 dslar.lions
<br />ocmlirion Pcrnrih.Ash.slos Noiific.lion Fcdc,,l RcSulalions (Tnb 40. f!n6)
<br />Rcqxircd IIncr of l'lorilic.rion
<br />l(nifyrhrr rhcfcdcrrlrr8xr i. \ r.lxrding r\t{{o\r. hvrl . ior t'lh.rhlc ri rhis nmrrr
<br />l.cnilyrld Ihr\trc rhis rt,tli.d it)tr $d s rc rhdihcrhivc in{nnn i.f i\.otrc.r lrgrccr'con,tlywirhtrllCiryrndCoutrry
<br />.'(li'rrrc\ nid Sfur.l-rtr! rcl[trE ro hu]kll0!rcpr.!.nrrnc\.lrhn ( irr md Couort k, rntr !t rlt
<br />rhovc nrnri,n(d ni{iIrnt r(n i'rstc.r
<br />DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Rool Sheathing i<//q.iic ;\ f<
<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 />Engineer Final Report
<br />Flood Zone Cenif
<br />-4,4 -.?\
<br />FINAL a6^L2-,b '247',7 7)
<br />Certilicate ol Occupancy \---/
<br />Notes, Remarks, Etc
<br />,\|,Dli.nnl ,r ,\xrnl Sixnah'n 4"7 CAn.
<br />SITE.WORK
<br />UFER Ground t-+-
<br />- T------
<br />(-,ni,1
<br />o" *'3t / -<
<br />e-s rc
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