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BUILDING- INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS OWNNR BUII-D!]R DEI-CARATI(IN
<br />I hcrchy lflifln undcr n.nnlry or l).rjury rhrr I tun.kc.fl Innn rltr C.nki.n8 l-iccn{ l-aw for rht n,ll.sirr-P rcr$n (Scc.7(J.ll5
<br />ausi'r.\\ ird Prtrfcs\n[ c.\].): Any Ciit or Counry whl.h rcquircr r lrrnnr k, rotr{ru.r. rlrcr. inpruvc- icmli\h ,{ rcFn rnv,
<br />qfldurc. prntr t) ns isruancc. rho rcqlirc\ rlrc applicatrr li,r \uchFnnir u rilo0 si!trcd sl cmnt lhllhcor\h. ir li..n\cd PUEnmr
<br />h rhc ln,vnn,ns ol rhc C.ita.rofs Li.cn{d LaR (Chrprcr q. Conrmcrcing wiri Sccrn,n 7flXl ol Divrion :l oI rhc Btr\n,cs rM
<br />Prolcs{iuNCodc)orrh{ln or rhc iscxcmpr rhcEliomand rhc br\is furhc tllcBcd cxcmplior Any!tthlionofSc.rk T(r:ll5hyin,
<br />rpplicrnr tn r li.rmir !ubjc.nrhc rprli.rm ro rci!ilrctrrlryotnor nu.ttutr iivc hdndrcd Jolh lS5(XJ)
<br />I. ds ow,f,r orth. prcrcny. or nycnDk,r€c\ wirh wBr.s !\ rhcir {ik compcnsarion, qilldo lhc sort nrlt itumnnnr
<br />irrcden or oilcrcd ihr $l€ (Sd.7044, Bu\i'Ess md Pior.s\i{,ns Cod.: TII Conrraclor's Liccn* tiw dN{ Dor dmly b 8tr oqNr ol
<br />rhcpmFny stu huild\ or nqJN\rs rhcrstr. dt wkJ des sNh qo hinNll or hc^elf or rhrcugh hn o. h.r osn cmpbtcc\,
<br />Drolidcd thar srch inlrevcrrnrs m mr inr.nd.i or orTeEd iu sab. ll ho*clci rtx- huildirS or imnrotnEnr is sld sirhin om }ti
<br />olorrphtrrn. rlk O*ncr Buitkr will hnvc thc burncn ol poving rhd hcor +c did tur huild or intmrt lhc Dmp.ny for rh- Puqr'{ of
<br />l. rt owtrcr or th. Uotcny. an cxclusivcly conrE.linB sirh li.ci{d ..nr&hx to consrud rhc poj(l (Sc. 7011, 3unrcs
<br />md l\,f$sion Codc IhcCont"cr.as t-i..trsc tjw d{$ nor rpl,lylo atrowner.II'repeny*ho build\.r nnprclcs lhcrcon.
<br />!trd Nho conrach r(n su.h ptuj..B with 0 Conn l.lo( s) liccnkd puru.nr rorhcConk,.ttr\ l-ic.n* Lrw)
<br />I rm.rrn,o !filr Sdri,
<br />{l,r I rl'a i{'tr n tr{rJ M!
<br />rfutaLwk
<br />nsrt,n i.\x rdmc .nnkr ntrd p.licy nunrbcr ec
<br />l.t.v I laL
<br />lccnifyrhrr inrhc p.rlo mnccol rhc sork nn which rhn prnnil n n\ucd.l shrlltrot cnrPloy!n, PcN)n innnynr ncr
<br />h is b bcco,m suhjsr ro rhc $o c^ c!6pcnsdn,n h*s orcrlin*ni.. nnd lgrce thar irl nx,uld h.c. r subiNr lo ih.
<br />workcn conrncn$rionpmvisn,n\ ofsccri()n SxDol rhc Lrhr Ci)dc.lslull.larrh*irh c.nrdy wirh rho( fmvnnnF
<br />WARNING: Flihr. ro r.urc w{rkcr' onpcnelion corcagc is unhsful. and \hdll subl..r ,)cr b fi.ri' |Imhas rDd
<br />l urgc\ r\ pnridcd lnr rhct, oN hr d'cd ihuoq dolhr\ (S100.(Xxr). ir &l,llli,)n n' rlr (o
<br />S.cri :1076 olrhc Irtxtr
<br />s"20tHAUG0
<br />I hcrct'y liltor utolcr Fn,lry olFrjuryrh.r I rm licenscd undcr rmvirion ofchaPr.r 9 (omntftin8 uith Sccri{in 7(ft).rDivNrn:l
<br />of rlr Busnrcs md Profc$ionsCodc, and my li..ns. n ir rullktr.c r cficcl
<br />TJ,looz76e
<br />A[.IG 0E 2018",*"..Fa.Gi
<br />I!]ISIBIJCIIONIENDING.AAEN.(;I
<br />t hcehyrfin undcrpcnrlirorpcrjuryIhrlrhcnis3otr(rucrionlc insuscncyrorrhcp.rror.umcolthcsorki{xrhi.hrhhlfnnirh
<br />is$cd(sN 1097. civ. c )
<br />a.Stulalr.D[cLAnalraN
<br />I Hryamm unncr pcnahyof pcrjury onc of rh. f(nbwint dftlu io,rs
<br />D.trrlinr Pcrtrrils.Asheslos Norificolion Fdlcral Rcgul,ion$ (Tilc 40, PanG)
<br />Rcauncd L.lrcr of Nolifr$rt,n
<br />-l
<br />ccnifyrhlr rhc fcdcE| r.eu|dio.s rcBsrdine ashcslos rcnn,vrl are rer npplicabL b rht pmj('.
<br />htniry thd t tat. rcad this applicarnnr utl irarc rhat rhc !h,vd inrrnr0riotr G conccl loExa ro conply wirh allCiy {nd Counry
<br />ordird .c\ ind sfurc lrNs rcllriry t' huikli"gc,
<br />rh)v. ff,nri(nrd fl.Itnr l(tr irNtcdni
<br />,\plliunr or \!rnr Sirnxlurr
<br />I'emrilee nrnr lpritri):Art.U l,o'
<br />"". "'*.t i,ifl
<br />,*tf
<br />"$"'
<br />fi hi i
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsulalion
<br />Rool Sheathinq
<br />Shear Wall
<br />Framinq b/6(ts iD ?,
<br />lnsu lation/E ne roy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Cefiif
<br />FINAL s{wlp tD(6
<br />Certificate ol Occupancy
<br />Notes, Remarks, Etc.
<br />SITE-WORK
<br />IYAf,BI8.S]JOIIIENIAIIQNo[clAnA rN
<br />I h.rcby rfflrmundm pcnalry of pcrjury om olthc nnhwiq dcchrarions:
<br />-thalclidwilttuinr0innCc{n[atcalConscnrtoSclilnsurcfor*o!ke^
<br />conF.\arn,n, $ poridcd for hy Sccrn .l?(x)orrh.
<br />Lihor Codc.ld lhe pcrr'or.Enft orrht work lor which rhc P,anir ic hsuci.
<br />I.ndc,-<Nnm
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<br />knrlci\ Addrcss:
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