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BUILDING- INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS <br />Set Backs <br />Form s/Steel/H o ldowns .poct- <br />Erection Pads I <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUl nsulation <br />Roof Sheathing <br />Framing <br />lnsu latio n/E ne rgy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />Handicap Req. <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />qllalV,t',JfuA\FINAL <br />Certificate of Occupancy frr \l <br />Noteq Remarks, f tc <br />lv-) <br />I U ULI <br />d 4 <br />?o utIIt't <br />OWNER B!N,DI]R D}:L(]ARATION <br />I hftby dmm ondd psalty olp€rjury rhal I d .r. pt 6on rh. (onrrscloa L'c.nse I-a* lor rhc aollowin-s rcMn (Sc 70ll.t <br />a6in6s d P.ohsion C.!c) An, Ciry or Coutrry which r.qut6 a ,6nn ro .otr(tud. .lts. imptolt. d.molish .r laon mv <br />srruc1uc. Fior ro ns isumc., ale r€quir6 lh. arplicd aor such pdnn io fiI. a sisned st3lddr lhd h. or sh. is licms.d puNel <br />ro rlE provGions ollh. Co.ulcloii Liansed tiw (Chopt6 9. Commocfls wnh Sdlion 7000 of Diviion I oflht Dsitrs md <br />Pbr6siois Cod.) or rhar h. or she is.rcmpt lh6.fro'n dd lh. b6sa ror rh. alLs.d crmprion. Any violalio. olSdion 7011.5 by uy <br />applicont forapmit subj€crhc applicanr ro..ivilp.n.hyolnol mor.lha lil. hun&.d dolles(S5(]O). <br />-1. <br />s o$nd olrhc Flpcny, ormy.nplo!.6 snh w+6 s th.ir sL compe6alrcn. uill d. rhc *ork d th. slrucl@ i! @r <br />inlarLd or ofided for elc (sc 704,1. Bdsin6s Md E'ofsioN Codc Thccontrldois Licds Law &d nolapplyb M own6 ol <br />rh. lmpdiy $ho &il& or inl!.o\61h6@n, s.d who dB n,.h ro,{ hi,ro€lfor h6.lf orrhmqh hs or hd om.mplo)16. <br />povidsl rhat su.h nproEmts ec nor inldnal o' ollEdi ftr s]. lr, how.rd. rlE huilding or nnprov(ffit is sld snhin onc y€r <br />of conlpErm. rhc Ownd &rikl6 *iU Mrc lnc bu&n ofp0ins thd h. or shc did nor build or inrpreE thc lmFly fot fi. purloF of <br />l.6o*n6oarh. propdy, m€xcltrsiv.lycontractinr rvilh licsscd.onkadou io connrucl rh. phrd (sd. 7014.ll$'n6 <br />md Ptllsion ('odc:1hc C.ntidof! Lic.ft. Law d.B nar arplylo an osns orpropdy sho builds ot imprcv6 rhd.on. <br />and sho contmds for such Fojclsrvnh. Contadn4s) li.6*d Pu6trdl lolh. cont.ctors Li.dk tisl <br />I m.rmd mdd s(ron . a & P( for rhls '.drn <br />voRKFRS' cOt\lPItNS tlON <br />!fc!48arla! <br />I hr.by af6rm undd p.n.lly ot psjury onc of thc lollo$inr d(l&atio6: <br />-r <br />havc .nd vill minkln a Cdilical. of CoBdl ro s.lf- lBut. fo. workec conrp.nsarion, E prolidcd for by Sdlio. I700 oilh. <br />Labor Cod., for thc FlomMcc of lh. so* for [hich lh. p@n is isu.d <br />-l <br />h.v. and willnainlain woi(.6' conpctuarion isur c..s r.quir.d by S.nDn 1700 ofrh. tjbor Codc, hr rh. pdfomeccof <br />rh. wo aor $hich lhir p.mit t Bsual My work.R comp@io, iNurec c&nd dd poli.y numb<r 6.:(atctn * <.r.(9apD cos <br />-l.dify <br />rhar inrh. pafonnnnce oflhc sul lor Nhi.h rlns p.tnn is issucd. I shdll.or dPloy any p€.so! in an, nMnd <br />s sto bqom. subj<l ro rh. $ort6 comp.realion lass orcalitumia, Md tsr thal ifl should b...m. sbidi to lh. <br />*orlsa conpdsrion prcvisions ofScclion 1700orlh. tlthr Codc.I s&ll.lonhsirh comply *irh tho* pIovisioB <br />WARNING: f.ilurc lo surc sorl6 .o'npd.lion cordasc is unlarvful ed shall subrcl u mpl.'d ro Lriminal PoakE ed <br />ciril lin6 up Io onc hundrcd rho$dd dollm (S100.0o0). in add'lio. ro rh. coe ol.omFnslion, dant86 a providcd ror lhc <br />Sdion 10?6 ol lh€ I zbr Cod.. inrd6t dd lnomcy's fG <br />(o-7GG <br />DECIABAIIIId <br />I hftby afirm unds pc.al! of rdjury ihtl I dn licd*d unda provisio. olchap(a I (connmcin! sith S..lioD ?000) ofDivisioo ] <br />ol th. aNin6 tud PrcfsioN Codc. ed ny li..N is in full forcc a.d ctrcl <br />3s-7'?E ?Cto <br />(o -3(-t3 /FW C.'eF <br />calilalllrolJ,DlDlNclcEdrI <br />t ha€by dmm undd Fnally of pgluly ihar rh6. t a .odrodio. kndins asdcy aor rh. pdaonnMc€ ollh€ sork for $ hich lhis Fmil i.e <br />Gsucd (S( l0q7-CN. c ) <br />af8llcANr-plclJsauo! <br />I hq&y afrm u.d6 p.n,hy of Fiury on€ of $c followiiS d(l,rarionsl <br />D.mohion Pmirs'asbmos Nolification F.d6al Rtsulat ione (Tnb 40. Pan6) <br />-Re!un.d <br />krld of Norili.arion <br />l.difythot rh. fed€Bl rcaulaxoN r.sdins asb6los rdnov.l u. nol ardicablc lo lhis poid. <br />1.61i$rh.r I havc,6d rhs apnli.ario.md$at.thal lheat v. infodalion is.ordl I asrE to cohrly Nilh all Cnv od Counly <br />ordin c6 d Shre Laps r.lalins rc bnildinS codrudion. ud h6€by authorift r.p6mlativ6 ofthis Cny MdCounlvto dtd upon Lh. <br />abov. mdrion.d porEr, aor iBp€dion purpos. <br />,\|,pli(rnr or Agdt Sig.ihr€rhrc /o- 9t-t8 <br />cA o <br />II <br />I,. <br />N <br />Shear Wall <br />T-Bar <br />L.ndd ! Irn( <br />- <br />--------T------ <br />It--+--