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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS
<br />Sel Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Rool Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsulationi Energy
<br />Qrywall
<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 Certif
<br />AY-t{-il
<br />Certilicate of Occu pancy
<br />OWNEI BUILDEN DOLCARATION
<br />I h.rcbt r(ion undcr ri.nalt, or Frjury rhar I m cxcmpr fmr. thc Co racror'l-iccnsc Law lor rhe tollo*in8 rca\on (sN.?O.ll5
<br />Busincs a.d Prclcesion Codc) An, Cily or Coutrry whi.h r.quircs . lranir i0 condncl. alrcr. inDn,vc. dcnBlhh or rcnJn Jtry
<br />srrucrurc. t''hrlo ils issuancc. aho rcauncs the orllic0nl for su.h pcflnil ro filc { si8rcd slalcmnl rhat lror shc is liccn*d pursurtrr
<br />lo rh. povhn s Dfrh. Cohrncroas t-i.cnsd trw lchrprcr 9. ConmctuinE wirh Su.lion ?flI) or Division 3 of llrc Bu\incss.nd r
<br />PmlcsionsCodc)orlh hcorshrhcxcmplrhcrcfior.ndrhcbisislorrhc.lhscdexcn]fliotr.AnyviolntionofSccrio.TOSl5brrny
<br />4rlica lor a pemir sub]ccls rte lrrlicanr lo acivilpcnaltyofmt mrclhan fivc hundred dolles I $5(n)
<br />-1.
<br />ns o{trcr of Ihc pmFny. (, nry cnplorrcs with w.8cs rt rhcn eh ompcnsdrion. will do rhc work d rtEstnrlmis mr
<br />inr.nd.n or.ftered lnr ele (S( 704.4. Ausircs and Pnlesions ('odc: Thc Contmdor'r Ltcnsc L!$ (lo* nor arplytJMowndor
<br />rhc pmp.nt who builds or nnFroks rh.mn. and who de\ such w.rk him\clf.r h.sclfor rhough his or hcr owncnDhyccs.
<br />providcd rhnr such inDotnrnb m tu inrcndcd or oltbrcd fff eb ll ,r*cvs. rhc brilding or inrpn,wmnt h sll wirhin o c ,ruorco.Dklir th€ Owmr Bui&lq *illha$ lhc budcn ol pmvinS rhlrtror she dn B tui! or ir{rcrc rh. pmp.ny ror rri pu{n{ or
<br />7--G*,,*n",nt,r'"n-n"ny.amc(lunvclyc nkr tr'g wirh li..n{d ..nta.roF ro con(ru.r rhc prclcd (sc 7{}ra, Blsines\- und PmFrsnnCodc: lhcConlmclolsLiccasc Lnw dncs nol lnflylo 0nowncrolpropcnywho builds or inpDlcsrhfic.n.md sho.onlrckrorruchtroj..lswnhaConhcro(s)licc!\cdru^uaiirorhcConkicroiiLicen*trs).
<br />,r,,,*F
<br />DECLA.STIIQIi
<br />I hcrchyalln rutrdcrtrtrdryof p.rjur!oicuf rltct l,iqi"tdNhr ri{rn
<br />lhdv. will rnnainrCcnitl.rtofcos.nrkrSclllNrr.litrworkcsompcnsrrn)n,rspn,vidcdftrbySccxotrl7l[)olthc
<br />LnhrGxlc, fu rhc lrrrorrun.. or rhc sork fd $hich rhc pcrmir is isucd
<br />_lnrvclnlwillDrinllinuorkcn conDcn\ltion inslrtrtrcc. N rcquncn hyScclion l?0Oollhc uhorGdc. fir rht tdr.nMNc 6r
<br />rhc *ork ior whici lhh!.rmil i\ tslcd MyworkcF onrpcnsnrn,tr insuraiccclricr rnd nolr} numb.r m
<br />PolicvNun$(. ExpirD\
<br />-
<br />.-}-
<br />I
<br />-\:",r, 't, .,* r*r.rnunlr r,hcsitrkritrtrhLtrrhisp.'m N i{ucd. r shll nur d,nrroyrDyp.,str r.trynrnnc'
<br />so s ro bccom {hjcd to rhc worlcr' conrpcnsdion hwr or calirdnra. d r8rc hd ifI shoutl hccom suijccl x'rtr
<br />uorkc^ conucns.tion ,mvhions ofScclion lT(x)olrhc Lahor C'odc.l shrll. n'nh$irhcompl) trilh rtDr pDvisn,n\
<br />WARNINC Failurc ro --urc *ork * .o.rt .sarion cov.6g. ir unhwful. Md shlll \uhjffr .r cmnlorr lo simmll pculrics and
<br />.iv'] lilrcs ut ro o . huidrcd rh.u\n dd.ll * lSl(I).1[X)). i'i ttrktirrtrr ti lh..on ol .on{'c
<br />a *
<br />DDII.ASAIXNI
<br />I hcrchydl,innrndcr pciahyotterju,rrhd I n liccdKt! crnnrvisi{rrofChrtrdr9(.omrrnc r!wiihSc.rion70t{r)otDivisbnl
<br />oi lhc ltu\inc$ rDd tt.tt$i,'ns Codc, ud nry liccn\c i\ ir l l lore xtcllcrr
<br />Conlr.ckr
<br />caNiilf,lsraNtENDtlc-dc.lNtr
<br />I hcmhyafln'nundcrlcialryofli.rjrr),rhd rhcrc hrcotrdru.rion hndingr8.ncy f{r rhc nt oiihrRd.frhcwurknrwhichlhispsnrir ir
<br />t\ucJ isr.' lo9'7 Civ a: I
<br />AttUcANflEcl 8iIUaN
<br />I hcrcby arlnr undcr pctrolry ol FrjLtry onc oirhc lollowirs dr-.hrrlnnr:
<br />Dcnmlirion Pcnnirs Asbc(os Norilicari.n FcdcrulRCBUhrions alirlc lo. Pln6)
<br />R.qun.d Irtt.r.f Norill.nri{r,
<br />I.cdirr rhal $c f.dcr.lEgxl.lions Eeanling nsbcnos e $v,l c nor amlicablc lo lhis l,loicl
<br />Z<.kca il, rhar I h.vc rcid rhi\ annlrar,"n md {orc rhd r hc ahovc inforrorion i\ c.trccr I agre ro ohply $irh all cil, ind counly
<br />onlinn.cc\ anJ Srarc hws rchrirE tr I'uildin8 con{rucri,r ird hrrcbyrurhornc
<br />!txrvc Nnriurcd pr.|cny for irrDccrion
<br />,\pplionl or AAcnl Sisn.lu
<br />4)
<br />,"K 3
<br />UDAMFINAL
<br />Notes, Remarks, Etc.
<br />;Z
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