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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE COMMENTS OTINER AUII,DT]R DELCAR-{TION
<br />I hcrcht rriinn trn,lcr F-nahy of p.rjury rhd I rm cre'nfl ln,r rhc (.ontr.i{trr l.iccn* liw lar thc folb*ins ruq)n lscc 70115
<br />llNi.c({ xl I'rofcsshn Cr c) Atry Clry or Counry shi.h rcqnnc\ r ncnn[ t' ..niN.t. i]rcr, inuo(. d.nrnkh , ru|nr rrt
<br />{ru.lu.c.l,rirtr lo iis is\urtr.c. rl\o rcquncr rhd aapli.Mr nn \kh rnn n) lilc a \i8md ntrs rnr rh.r hcor \hc n li.ct\crl Nnn n
<br />lo rhc pnrv$i(,r\ or'hc C.ntr.ttr s l.iccnscJ lrrv (Chrprcr e. (onrnEncin-! Lvilh Sccrion ,{xx) of l)ivisior.l ol thc llu\nt( rtul
<br />PFICsirlN Co']c ) or rhd hcor\hc iscrcnpr rhcrcfromrnd rhc hr\i\ lbrrhc,lleEcd.ic,n|ri,n, Any!i()larionofSo.rii)n70:rl5byitry
<br />rp0li.nlhrrp.rnil{njcctsthcr!nli..nlfur.irilpcnrlryornor xrcrlrnivchundrc.td.llanlS5(D)
<br />I. as ownf of rh. I,sFny, or my cnrrlnyc.\ wirh *agcs !s lhei v)L .ohr.n\i ion. will rk, rh work aJd tl.. nf,duE ir mr
<br />irlcnd.n or oficBd for $lc (SN.7(x4, ausimss and Pmfcsson\ Cdlc: Thc Conrrrois Lic.ns Llw {Lcs nol alrply b d owmr of
<br />rhc pn{rdy wh) hikls or i'nEo\t. rhetun. and lho des su.h sor* himsclfor hf*lfor rhn,nrh ht or hcr o*n.npbyc.\.
<br />ttuvidcd rh,i \dch impmrdmnc tm ft, inrcndcl or olliR\l rbr rrL li k'*cvcr. rh. hritlin! or inrtiovcmd h srkl wirih onc F
<br />oaconlPkrion. rhc Owncr Buildcr *illhavc rht hurdcn of!rcvins rhlr h. or she dit nor huild or i.rtmr rht pmFiy ror thc nu4ns ol
<br />I..s.wncrufrhc[op.ny.amcr.luliv.ly.!.kkrn€sirhlicc\cd.utrtrdoNto..iNn]cllhct're]c.r(Scc7(n4.Bu\in.\i
<br />dnd PhlLs\knt(--odc:'lhcC.nrrcroasLi.cnscl,!wdocrnor,pllyt,tr otr icr of pm|En, whn hr ilds or imprvcs rhcrcon,
<br />and *ho.onrmclslorsuchrm]l-cbrirh.ContadontliccnqdNr{r lorhcConlrndoasl,iccn\cLa*)
<br />(yt &,
<br />t a(),,\R,\tt()N
<br />Ihcnh, rllnnutrdrrruMlrtof Friur!o cot(hcln
<br />l hrvcdrl will nrrrair a Ccn ilsdr. oi Conenr to Sclflnsurc f(tr *orkc c.mtcnvnion.'\ pmridcd aor by Ssrnr 3TU) .f thc
<br />tjtr)rAdc. fr rh. p.rfonMrc ot rhc $oA for shich rh. p.nnd i\ hsuql
<br />I h.vc trnd sill.rrirt0ir sork.rr .o"rF-ns0rion inrmncc. r\ rcquircd hySccrion.lTfi)orrfi. LrhorCodc. forlhc pcrlhrnmrccoa
<br />rhc work lir shLhrhis pcnnir is isu.{ Mrworkcrs'conrlcnsd(rr iNurrncc caricrundIi'li.} nunh.r tu l
<br />Policy Numhc! Jrpircs
<br />I.cnify rhrr in rh. priformmc olrh. work f(tr *hi.h rhn pnnir i\ i$ucn. I shrll mr cDnn,y 8ny pcrsn h niy matrmr
<br />h as ro n{nrE \ulrj$l lolhc$orkcF'conrcn\erion larrofcalitmir- md asr.rharirr lrr,rld lu.*.rft subj.Yr Iorhc
<br />*ortcn coDpctrsrrion provisions olSdn,n l?(X)ofrh. Lihor Cdc.l \tu]1, fodhwnh.o'nPly wlh rhoc Dmvisions
<br />WARNINGT I'rilurc lo $curc wortc^ .ompcns io. mrm8c i\ unhilul. nnd \hrll \!ht.! M c'nnk,ycr ro rimiMl pcmrlics ind
<br />.ivil ntr.s trp nr orc hundrcd lhousud dollm (SI00 n niri,r r,, rh. cod or c.nI.nurior. d,nm8cs rs lrovidc(l lor rhc
<br />i,Jo'[1',:;1;a;"*'1
<br />I hcrhynllnmu cr l{n.hy.fncrjrry lhnr Irn,lictrslundcr prri\ion.fChit'r.r I (..nnrEncnA w irh S(rio,r ?(xxr) or llirnit)n.l
<br />of rhc Busincslnd Prolc$iorNCodc. !,xl.ry liccns n in tull rirEc rnd.nccr
<br />I!]NEIBIJIIIONIINDINGIAINCI
<br />I hcrchy,flnflnMcr Fn,hrofl'crjury rhd lhm h ! onsrruciion lcndins lscNy f{, rh. pc omutuc olthcNoik l(}rsni.hrhn pcrmn n
<br />hsu.d rsm.:109?. Civ. C.r
<br />AIIUC/INLITESAAAIIoN
<br />I holt'y fiim undcr Dctrrhy olFrjury onc orrtc lollo*in8 nchrlrion\:
<br />hnxrnt,. PciinnlAsti.slos Nolificarion lcdcral ltcBulations (Inb 40, Prn6)
<br />-Rcquncd
<br />Ldlclor Nolific ion
<br />I.cnilyrhd rhc ladcrrl rcgnhrn[! 19d in! r\6cslo\ niEtrn]rrc n.lrplli. hlc h rhn |m)rcrr
<br />_l ccailr!rhrr lhlvc rcld rhhamlictrrioi Ud nd.rhd rhcrh,vr nnnrnr notr i\cor(r I ngra ro comply *irh rll Ciry rtul Coutrrt
<br />ordimn.rs rnd Sr3rc l;Ns rcht huildi{ con{flcrion. and hcrchy.urlkriz. iqrcrnhrivc\ ol rhi\ Cir! aid Coonry kJ cfrd unotr rhc
<br />rirorc nrorioncd liropcny ht
<br />Appliunl ' ,\!rnt Sirnslu
<br />gr*c4 N c{.rlo. (,.,.otb-]-atc6-' '
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />Subf loor/VenVlnsulation
<br />Rool Sheathinq
<br />Shear Wall (86re 4a-2 7 rlzql; lo/2lrz,n-ifi
<br />Framinq I
<br />lnsulationi Energy
<br />Drywall
<br />Brown Coat
<br />[/ason rY
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />I
<br />FINAL .ffiq
<br />Certiticate ol Occu TTT tpancy
<br />Notes, Remarks, Etc
<br />ID/SIG.
<br />Forms/Steel/Holdowns
<br />SLAB Floor
<br />Ext./lnt. Lath
<br />Flood Zone Cefiif .
<br />lohul16
<br />(-,-:- /--,la- -/ - A
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