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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE tDistG.COMMENTS oWNER BI'II,DI]R DF]I-CARA'fION
<br />lncrcby.fftrmu cr Frtrilly of pcrjury lhrl I aflr cxctrrpt liorn rhc Conticlorr l-i.cnsc l,aN fttr rh. i(nbsi s tci$n (sc70:11.5
<br />!ru\i'r$s rnd Pmtusnrn Cqlcr Any Ciry or Counry {hich rcqutcs r pci,nir b con{turr. alr.r inpn,vc, dcnn,lish .r rcnrn rny
<br />{rucrurc. prirb irs is\Dtrnrc. rho
<br />'cqurcs
<br />rh. {rli..nr for \x.h lj.nnn r. filc. si8trcd sl crftnl rhd lEo! sh. is liccn*d pu'strrnr
<br />lo rhc F)rhiors oI lhc Contrnclr\ Lice.*d liw (Chaprc! 9. (onrnrcncinE sirh sccri,)n 7(xD or Diri\ion I ol lhc Busincrs rnd
<br />Pmfcsi,,n\c{ cr.rrhrrhcor\h.t.r.'nptrhcr.fromandihchr\i\turrhealtlcdcx.nDrk.Atryviolatiotrofs$rhn?0ll5byrny
<br />rD,rli(rtrrntr.,rnnirsubl..tsrhc.!pli.rnllorcivilDcnilrtofnornxr.rhatrlirchundEdd.llan(S5fi))
<br />La\ orftr.rrhrpnrjr'ry..r ry cnll]loyccs qirh q,Ec( ,( rhcn \rc .o'npctrsrrii,n. *ill do rhc strk ml rhc nndk n no'
<br />inlcnddl or oficrcd tu slc (S.r.701-4. Ausirc$ ind Pror'c$ions aGlc I hc (bnrDdo.s l ,lccnsc l-rw doc\ nor q,ply t, rn oqNr ol
<br />rhr pR,pcny whotn'lL{1\or i'npm(cs rh.ft,d. and *ho docssuchNor[ hi'n\clforhrrsr]forrhn,u!h hi\ or hct wn.nlnloyccs.
<br />o,.o fLrion. rlr Owtur Buildcr will hrlt thc ttrtrdcn of pr.ving rhd h. or \h. did nol hulkl or inllrot! lhc lmtrny l.r rlr Plrlx,{ of
<br />I ntrrcxcnr trndcr Sc.r
<br />Drlc Olne.
<br />woRI(uts' c-oMPttNsaiioN
<br />llE!lrI&U&!
<br />I hcrchy.tlirnrundcr |tnnlryolperjuryone olrhc ialkrsins dcclnrario.s:
<br />-lhtrvc
<br />a'dwillnrn rir0CcnificarcofColscrrroSelflnsurclorwortcrr'co,npcnsnnnr.N ptuvnbd lbf hy Seiion 3Tur o l rhc
<br />ttrtxtrGic.rorrhcpcrlonn0nc.of lhewort,nrwhichlhcDcrnir ni\{Ed.
<br />l hdr rnd willn,ri' ri'r tro.kc( c. rNn\it ird{hi.c,r\,.qtrncdhtS.criotr:17{[).lrlrctjhorCodc.forrhcn(f,trhatr(of
<br />rltr *ork ror$ti.h rhnFrnriri\ i\lxcd My sork.rf ..nrr.n{rn nr\urm.c.rricroitni.ynumhcrirc
<br />cdri.r SUS'( €^r..Jqz\7-7 I 1 lnT1
<br />-lccnili
<br />rhar ir thc pcrrbirro.cc oilhc *ork l'or which Ihis nennir h hsucd. I shrllnor cnlPloy an, pc*on in.ny m,trtrcr
<br />$ a\ k, hccom srhjccr k,rhc workri.omp.n\ n,i h$rof Crlin,mia. Md l8mrhd if l should hccom suhFr lorhc
<br />worker\ comrcnsarion pn,vi\n,n\ ofS(ri(,n lT0Oofrhd Lahr Ctxh,I shlll bnhsirh.nnl,tly girh rhoe px,!i\n,tr\
<br />W,{RNIN(:: E,ilurc ro rcurc wor*.n comFn\dt,n corcf,{c n uihwlul. and \h.ll ublccr rtr emplo}cr r. riarind p.nahtr md
<br />.ivil nner !p b oie hrdrcd rhorsrnd dolld l$lo0,rxm), in addir n b rhc.ost of.omlrNrtion. d mgc\ !\ pmvidcd for rhc
<br />Su!rn,n :1076!f DclrhtrCo'lc inrerc{trtrd Jtohcv'\tlr.ltn"". 7f zvf t 7 ^pprr*n,:
<br />.-A+
<br />LIIIISEL(aNIBAIITB
<br />DICIABAIION
<br />I hcrhy rlitflrundc. !.nsllyoipcrjury rlHr I m li.cn{n undcr pr'!isi,,n orChdntd I (.onnrrrcinp wirh Sccrion 7(xx)rofDi!i\i,,n.l
<br />ol thc Busirr$ alrd ProfcsnorsCodc. md my liccnsc h in lullforccanncllNr
<br />B ,.-r**-r*r,-ZAib o3z/{z ,.",,*,",5sk Sef @akL^'T:^t L,
<br />ca$flf,lJEIllTNl.ENUNC-AC!NlJI
<br />I hcrchy rflnm undcr pcnrlr, ol lcrjury rhrr rhcrc h u.onsrdcri)n b.din! ascncy tor thc l)cl ronnincc ofrhc sork t, whichrhi\ Fnnir i1
<br />Gsuen (Scc.3097. Civ. C.)
<br />AIIUAANLIDCIrIBAIIo\
<br />I )frhyillmundcr pcnrlry ofp$rrry om oflhc tulk,einA dc.le,rn \
<br />,Xnnit,n Pcflnih A\tE(o\ Norifi.ari.n Fcddrrl Rclul io.s ffik.t0, Pd6)
<br />R.qrt d Irtrcr of Norifi ..rirr
<br />I ccnifyrhirlhc lidcrrlrcEUl,riotr\ rcgartlnB r\hnosrcnrvrlx,c norrptli.nblc t) rhi{ pn,r..l
<br />uhrc rrctrri,,md nruncny lhr ins'l(dion rur[i,{\
<br />^poticnnto.^Eentstsnatuft
<br />7b'4-
<br />""*u*.,-,,0n^u, "/J,21*hl /-z.t..r-l^l''
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />ext.6i'IatV '4111 tq ,t t4r4ff1.,PtPr aa4'l,tL
<br />Brown-E-oat I t
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL a4/nE)
<br />Certilicate of Occu pancy
<br />Notes, Remarks, Etc
<br />Flood Zone Certif .
<br />8/tiltB
<br />-1.
<br />rs orn.r of rhc fl.Jf,ny, am cxchrncly contd ir! wirh licc.scd conlricr.F ro con<rucl rhc pm]ccr (S( 7l}tt, B$incs\
<br />rnd Ihr siriCodc: rncContr.rG s Lic.n\c l-trw doe\ nor rprlyk, rnownforpfuf,jnywho hxildsor nn0rcvcs lhcrcon-
<br />rnd who.onfuhrrru.nrojcchwir[rConrm.k'ngli.cnsdrnuNdtrrrorhcO,nrrrcttrsLiccnscl!w)
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