|
BUILDING. INSPECTOR RECORD
<br />ID/SIG.COMMENTSSITE.WORK DATE
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVlnsulation
<br />Rool Sheathin
<br />Shear Wall
<br />Fram in
<br />lnsulation/Ene
<br />allD
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlason
<br />Pool Fence
<br />T-Bar
<br />Handica Re
<br />ineer Final R ortE
<br />Flood Zone Cenif
<br />FINAL
<br />Certificate ol Occu n
<br />Notes Remarks, Etc
<br />atriNFiR BUrt,oER DEl,c,\R,1Il(rN
<br />I hcrchy alltrd undcr pcnrlry of pcrrury rhlr I d.xcmpr ls,n rhc Co.lrlcrois Li.cnsc hw for lhc folbsnrS tcaen rs"?0115
<br />Arincs\ t Proir$nr codcrr Any Ciry or Counrv ehi.h rcquircs I Frnnl Io condn't' ahcr. imPov' &nDhh or reroi lnv
<br />ntu.ruc. prior ro ir\ issuarcc. als. rcquircs thc qrplics ror such lcrnir ro lilc o sisncd stdcmnl rhd h' u shc k li'ssd ll!6ud
<br />n, rhc p(,lisioDs of rhe Contacror's Li.{i\cd Lrw (ChoPlcr 9. Commcncnrg qirh Sccrion TOID oi Divi{ion :l olrh' Btr(in's 3nd
<br />prohs;ionscodc)orrhathcor\hci\cxc,np hcrclion drhcbastforrhctrltcscdc{cnrprnnr.Anrviotarionotsccrir.r0lt5hyrtry
<br />rpplictrnr aora |J.rnlil srbjcclsrhc qrlliconr l', acivilpcnallvofnor nDrcrhun rive huMreddollrs (S5tx))
<br />l. ff o$n.r of rhc pnrP.rl y. or my cnploFcs *irh wr8cs as rh.t n,lc cotrIEnsdnrn. will do rhc *'it dxl rhe {nf,NE k nn
<br />i,,r-a.a - nno"a r*.r" ts- ?oi,l. B!\incss md Pmnsionr codcr Thc Coitr.toas l.iene hw doc\ nor
<br />'F,'lv
<br />ro 'n'wn'r ol
<br />rhc fmp.ny who h{ildl ot inrrrorcsrlrmn. I wh, dml such Mlt hiatrclf or hcr*lf or rlmuah hir or hcr own 'ftPhvccs'ptnitia ,r," .,"l' improtnrtrs rE ml hr.ndc .r o,lcEYl for sL. tl ho*cvcr. rh' hurldinc or i'qroknr n e)u I irhin "tu vt'u
<br />;r.onDbr,on. rlrc Own; tnilds *iu hnw lhc hrdcnorlmvin8 rhd h. o! shc dil ftn hoild or inqrn'c rhc pn'I(nv ror lhc I rF* ur
<br />I.rsowrcrorrhclnolcny.idcxclusivclycontd.rilrSwilhliEnscd.otrlhcldsnic'n(rudihepmlccllsd'?04'1-Busincss
<br />o,,r n,r*."n cna",i t" c,,nuaclois Li.cnr. t,i* docs nor alptvlo !no,i.! ofPrrFnv aho builds oi nn[ovcs rhcrcotr'
<br />atut qho conrr,ch ftx sucn pt,J..k wilh ! Co tu bns) ri.cn\cd Ntru!,r ro rh' contaclor'r l-icctr* ljwr
<br />/3 q
<br />I hrrcby aflnm undcr pcMlryotpcrjnry one olOc (.llowin8 dslarnrions:
<br />-lh,!.Udwiuminlainaccrlif'.dlcofcon*nll0s.lnsucforworlcn,.onlFnsalion.!sFovidcdlorb,s.clion]?filoflhcLltxn Cod., tbr lhc rcrformmc ol rhc {oik ror which rh. Fmi ( hsucil
<br />I hovc and will m,inlaifl work.rs comDenslrion imutuncc. as dqnircn bv Se'r ion l?m 'f rh' tjbor C'd' lor lhe Flfofmn" or
<br />ihc mrt for which rhh I'.rdn is issucd. My uorkc*' oDPenBrion insuramc.ari.r orn policv nunlbct @:
<br />crricr-
<br />l'di.yNnnhcr:--IixDir.s _
<br />-l
<br />ccniryrhar in lhc Frrai,ninccollhe work rui whichlnt Pcrnril
<br />$ ar b hconrc subj..r (' lhc wo.ks\ ..nrp.trrrrion lns\ olc.lilorn
<br />w.rlcB co p(trqri.n Pmvision\ ofSccrion llTtx)ofrhc Llhr C.d..
<br />WAI{NINGT F lurc ro {dr. workc6 .\'frFtr$rion colcralc s u
<br />is i$drtl.I \hillnrr.nuloyrnr_ Pcr\rli|my trr trcr
<br />ia. r d rArccrhri il l\hould h.c(nt nrh,cd ttrlr
<br />I \hr!1. lnnhrvir I c. nrPly { nh rhi{ In'vni(ff
<br />sIul. rnd rh!ll \uhjt.r in cnrnlolcr !) qi'nrnrl |].Nlrit\ rtrtl
<br />Li\ I 1n,.\ uri n, .m htrn,l't rhotr\rnd Jo lr\ ((l(xr.{Xr)r. trr )n i, rl[ co{ of coiD.n{li{,r,
<br />::::;/ryi;,'.:
<br />Ihcrchyrllt undcrPnrlr,olptrjurylh.lI3nrlir.nwlu cr |mrviv.r nl'Chllpr$ 9 (
<br />'ornDt '
<br />irr8 wilh SNri('r 7UXl ) '
<br />CONSTIITICTI(IN I I'NDINC ACFN(]Y
<br />! hcrcby lltm u.d.r |Inill,ofpc4uryihll lhcrc i\ l.o|nruclion lcfi]i.! !3cn.' ror lhc P.rformncc oflhc solt lirr whih lhjl [j(rnlil i\
<br />k\ucd (S.. 1091. Ci! C )
<br />Lrndci\ Addrc\s
<br />AIjUIANIDSCLAMNON
<br />I tErb!.Jlmn unrlcr p.n{lryofpcrjury onc ofthc ti,lk'wnrg dccli&liois:
<br />Dcm,lirh. Pcrn ls A.hcsos Notilicar n FcdcralRcsuhrnris (Tillc40. Pin6)
<br />-Rcquircd
<br />t llcrotNorili.albn
<br />-l
<br />ccnifylhar rhc lcdcr! I .cgllot io ns rcAUding asttso\ E@v,l,tc nor arPlhnhlc ro lhk Imlccl
<br />-l
<br />ccniryrhal I h.vc rcad rhis aPpLic,rn,n dld sialclhd rhc fi)vc irtonn.rn nconccr'Iagrero'onlplvBirhrllCitvandCoonrv
<br />ffio-,ina srnr" t-u*,.rnrind io buitding coNrtudis,rxr hcrchylulhorizc rcprc$nr ivcs!frhrcnyundcounryrocnrcrunotrrnc
<br />il).\. nrtrri(tritl |m,inriy lnr
<br />,tppliLrN or a.nl si8nrlr
<br />(@,*-
<br />617 "Q0o7c?
<br />of rhc Ausirc$ !nd Pnrfc*iorN Codc. dnl nry li(cn\d is ir lull lorcc dl.ll.cr
<br />Erection Pads
<br />7/f4,*;\<a
<br />DeDutv Final ReDort
<br />n
<br />d.t / tD/t6 tu
|