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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsulation
<br />Roof Sheathinq I qlta/D e '1 -./,u.d|y /t
<br />Shear Wall
<br />Framing
<br />lnsu lation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It/lasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil.
<br />I
<br />FINAL v/////tr 4*<)t/)
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc
<br />OWNER BT]ILI,,ER DEI,CA RATION
<br />I hcrcby drrnn u c! pcnrlry {,i pcrjrry rhrr I3 r cr.nln rro rh. coiirr.rois LiLTns Law for rhc i.ln,sina rcuv'n (sc.7011.5
<br />Bu\in.\r rid I'}bfc*ion Codc) A.y Cir, or Coutrly whi.h rcquncs r pcnnil ro condDcr. dr$. inftuuc. Jcmolnh ,{ tPeir iny
<br />(rudurc. ritrlo irs hs!.mc. aho rcqunes rhclPrlicmr ior \uchFrfrirk, fil.r ssncil $alcrmllI rharhcor shc ir li(cn\cd pu^nrhr
<br />t, rhc ptuvi\ n\ ofrh. Contd.ror's Li.cnscd ljw (Chrpt.r 9, aonnmncirg *irh S.cri.n 7Om ofDivnion I oilhc llu\incs rnd
<br />Prdc\snnNCodcr rrnorhco.\hchcx. prrhcrcfro'nJndrh.ha\i\f(rrht.ll.Bcd.icmlrion.Anyriolarionorsc.ri,nT0,ll5byrn!
<br />applicrnr li,r r p.nni' srhj..r rh. apllic,nr ro rcivilpc.,lryofnornucrhm ivc nundrcd dollrs (S5fi,
<br />l. ir o*ncr of rhc nmncrly- or my cmpbrecs *irh wr8es n\ rlcn {,l. cunl!. snr i.n. qix do rlE w(nk ad rh( {tursr i' ({
<br />inrc lcd or oficrcd for $lc I Ss 7O'r4. Bu\in.s Md Piofcsri,,ns C,xL Thc Cont{clois Lilrnsc l-lq d{*\ ior llrly t' !n owncr ol
<br />rh. F)p.n, whobuilds.r inymrcr rhcmn. and Bho des skh $ork himsell or h.rrllor ihmugh his or hd oencaPloy.c\.
<br />pn,v i,lc{! rh(l su.h irnprorcnrnrr am nor i' ctulcd or .ftrst n sL. lr. lx,scvcr, rh. hurlJnE .r iq'r,vcmnr i\ $l1 {irhin oN }td
<br />.f.. rdcridr, rtr Owmr Buildq rill hlvc thc hurdcn ol nnrrins rhxr hc or \hc dii ior build .r nl9(rt dE l,n,tsy l',,r rhc poqrM ol
<br />rn,l *lD .otrhd\,6 {'dpnird\sirhr(i 'i.nnr\)li(tr{atpursnfrorhc(tn,l.rclor\l-i.cn\cL]sr
<br />I mcxcnr trtrdcr Sccli{l
<br />Dnler O*n.r:
<br />rvonxpns' corrnni,lrror
<br />DEllillA.IIA!
<br />I hcrrhy rfilrm trndcr pcnalryofpcrruryorr olrhc lolbwir8 J(hrrlioN
<br />-l
<br />hrrc el *ill roirrai', a Ccnili.arc of Con\.nr ro Scli- INue tu tr orkcr' conpensarion. a\ ptuvidcd for by Sdi(,n 37m oI rhc
<br />tjbor CGlc, irxlhc pcrioflrunc! olrhc w.* for $hich rh. I.rn i\ rssucd.
<br />I hrvc rtul *ill ri' .i'r wor*cF ..qEnrar ioo iFunnr.c. tr\ rcquircd hyS.dn)n:lTLrOol rhc L.l!tC.d..li)r rh. P.rrornu! or
<br />rhc work r(tr whkh rhi\l[anir is ksucn. My *okcrr .ont,cn{rri({r i',\uxmcc c ri$ tud !.li.y N.rhcr arc:
<br />Iccniryrhrr nrlhc pcrtonnancc oirhc work lnr whichrhilrntrnil is i$ur . I \hrl! nor cmploy rtry pcrron in r y rtrrcr
<br />$ !\lo h$om subFr rorhc*orkc co.rr.nsari(,n h*!olCrhturni{. imlosrcc lird il l \lv,!ld h..oN suhjcrrrorhc
<br />$o*.s compcnsrrion pmvkion\ ofSN.oi]?m., rlt lrtxtr C,rl..l shlll. ii,nh$irIcon{ry wirhrhosc trovisior\
<br />IVARNIN(; tr$|trtu t) r.u,c qorkcrs c.nDcnslrio (1)vcrUc i\ urhqtul. rnd \hrll \uhjccr ii
<br />t, otrc hr drcd lhouslml doluA lsl l,lihr ro rlr coi of.o
<br />IIDCIJSAIIUN
<br />u ., provisionof Chaprcr9(.onn*NirE *iriSsri)d 7(XX)) of Di!i\i( 1I h.rcby rrrirn uidcr n nrlr, ol t'crjry rhir I am I
<br />of rhc Bu\in.\\ ud Pn)rc\nonsCodc. nnd mylrcr{ n ir lull li'r(c rrlclli.r
<br />..1
<br />Dj'Dx,. 1)v a'a^
<br />Ih.rchy rrft rtr d0 lrtri Iyol Nrlryl n(Dcli{D l. ing rgcncy nr rhc Nni,rmMcc ollhc $.'k l{tr {l,ich rlr^ lki,ni '\i\{'.(llS.. .1097. Cir C )
<br />A.EIUCAILPECLAf,AIAN
<br />I h.rc'l,y nrtimr undc. pcnalry oi perjuly oN or rhc r(rk,trin! d(lar idr
<br />Dcnnniior Pcbnih Asbcrkx Noriac.lion ltdcBl Rcgnhri,,n\ lTirlc.l0. Prn6)
<br />-R.quncd
<br />bilcr of Notifi colion
<br />hclc cril rcAnlarions reg liDg!sh.(o\r.unil . nor{{lL.rhlc kJrhis frolc.r
<br />!r 'r.,. I . ,fr'.r .{, tr!l ri1.rl { rl. nr \. tr' .1i ir Ur.. b.. nfly\irh ll(iryrnJ(,{tr y
<br />I-rw\ rcarii! ki builtli',9 conrru.1i,r,. r h.r.htx lhr /c
<br />ltn! h irst{cri({ fLrf,n:\
<br />'*{"'tz a
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<br />ID/SIG.COMMENTS
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