|
BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER OELCARATION
<br />I hcEhy orfinn unacr !.nrlly of pcrjlry lhlr I m crcmp' from rhc Conracton Licensc ljw Lr lhc follosinE rcr$n (Scc 70:rl 5
<br />Bu\incsr and Pmfc$ion Codc): Any Ciry or CDUnl, *hich .cqui.cs a rimil ro co.{dcr, llrcr. idlrov.. Ltmlish ur rlln ,ny
<br />!r rrurc. Ei{n ro ns hslance- als. equt r Ihe {,pliclor for uch F ni b ,ik a iG@d {ar.mm rhrt tr or sh. Ls liccnscd pu6ua
<br />lo lhc !6vis,Dns orth. Conracbls Liccnsd Law {ch,pr$ 9, Co'nncn.in8 qilh Scclion 70(x) or Dilision 3 of lhc Blrincs lnd
<br />PmlcssiotrsCodclorlhnlhcorshcncrcnDllhcrcrroar.lldlncbasislorrhc{llcgcdcxcmption.AnyviolulionofSccrioiT0ll5bydiy
<br />applicrnrr'or!pcrnrilsuhjcclslhc applicaor lo !civilren6ltyornot mrc li.n lilc hundrcd doll{s {$5C$).
<br />-l-rsowrcrorlhclrorcny.o,nryempl.rrcs*jthwo8cs!slhcnsotcomDcnsalt,n,willdorh[wo
<br />ddrtr$Mur0ismt
<br />inlcidcd or off.r.d nn ek {SLi 7044. ausin.ss and l']rolcs\k,ns C(xlc: Thc Cofu..rof\ Li.cnsc Lrw docs nol apply to an ovn( ol'
<br />rhc F,pcdy *io tuilJ\or i'ry,rorcs thcn,n, rJd *hodessrh*orl himlclforhc^cTforrhdo8hhi\orhcr.wncnlt]loyccs.
<br />orovidcd rh!( such i,nDmvcmnc m not inrcnd.d or olfcr\l fd *lc Il hoBcvci rhc huikli4 or inrfroEnEnl is sh wirhin on. ,t r
<br />ol.omtlcrion.rh.OwncrBriH..witlhrv.rh.hrdcnoipn iog rhrr lE or she dii frn boiU oi nrr6R dc pmFny ior th. puqnr ol
<br />-l.,so*n.rorrhc
<br />In)Fny. merclusivcly.ontdinp wnh b(ns.d conh.lo^ lo connrucl rhc pmi.l (S(. 7044- Btsirc\\
<br />and l\lrfssion Cod.: Thc Conrrlcror's Liccnsc Law docs mr lprly ro sr o$..r ofDn,pcny who huilds or inpmlcs lhc..on.
<br />lnd eho .o.rnds fttr such tmjcds wirh n Conta.k,(s) li...scd 0uNa b lhc (nnradols Liansc Law)
<br />I r cx. t urdcr Sccrtrn ,8. & PC larrhisms.n
<br />l)ale: Oqn€r:
<br />UOBKEBIL.SAUII'NSAIIONI)[lLAtArIa!
<br />I hcrcby rlii n utrdcr lEnrlly of Frjury onc ol lhc nnh*fu dccfuiol ions:
<br />I harc!fr1$illmi trh, Ccnin at ofCoo\enr b Scll lnsnr.lor $ ork.r' ompcn\dn,n. rs ,tur idcd fo. bySccti{,n 37m ol thc
<br />ljhn Codc.lor lhc n.rformlnccollic *ort,hr *hich rh. pcmir t hsuct
<br />Ihrrc,ni]willmainrsinu.rkracompcns.rhninsxran.c,rsrcquir.dbySsrion17(x)olrhcLrhorCodc,forrh.pcrto(tukcof
<br />thc work for *hi.hrhh p.rnir is ksu.t. My workcm .onp.nsarion i.summccmicr d poli.y numbcr sc:
<br />-l
<br />ceniiyrhlr ininc pcriormnccoflhe *ork tor which rhn p.rar h nslcd.l \ball nor cn,rtoytrnypfsn in lnym.nncr
<br />s * ro b..om rubF.r lo rh. wolrcn' comp.nsrn r h*s or calirorn$, md aBrce th0l il I sh,uld h(om subjcd b rhc
<br />qorkcrJ co'ry.ns,rion povnions oi Scclion 37u) ol lhc trbor cGlc. I shall. fonhsirh $mply *irh rhoE pdli\hn{
<br />WARNINC: ljailurc ro scurc workcr'.oqrcnsbn oven$ is unla$tu|. snd \hall \rbi{ m cnrt)lo}ry ro aiminalFnrlri\ rnd
<br />civil fin.s up to otrc huod,cd rhousard dollu\ (S,0O.0OO)- in lddilion ro rhc.od nr.o'hFn\drion. d.m,gcs rs prorilcd for rhc
<br />Sr.rnnr:llrT6olrhc litxtr Cod.. inrcrcd Md orf,y r 1..a-lo-rn
<br />ITES,AAA.IION
<br />I hercb) 0ifimundcr pcnollyo{lcrjury lhar I rm licctrsd undcr pmvhion olcharrcr 9(con,ftncins qirh scclion r00o) ofOivkion.l
<br />of thc Buircs md Pmf.$ions Codc. md nry licctr* is i. tu|l lorcc url clitct.
<br />D.i", 7-ltr-l E c-r.*r..
<br />cllltirtrcuaNtENDllcili[Nlx
<br />I hcdby firm undcr pc.,lryofF4uryrhn hd. i! r 6n{ddhn hnding ag.n.y ror rhc pcrlorrurcc otrhc solk fo. which rhi\ pctdir i\
<br />hslcd iscc.3097. Civ. C.).
<br />t trdci' t'Jntr
<br />ATILIIANLOECI.ABAIPN
<br />I llrtb! nflim undrr p.nrlry ofpcrjury onc ofrhc ftrlloRing d.clarri,n\:
<br />D.m,lin t I'crni( Ashnor Norin.dion F.dcrrlRcglbrnns (Tirl.J0. Pd6)
<br />Rcquftd ld$of Norifr i(trr
<br />l.cnnyrhr hc ltdcirl rc8ulations rcAelin8.\h.s.s rc rularc mr {Dflic0hle lo lhi\ prctecl
<br />raou nEntnnrctl nn|Enylnr iNncc
<br />/\rpliro or,\lulSilnrlurc 7.rl1A
<br />1.,1 C z'.2- r.&\-
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lr/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL s-7t-ly v:&")il
<br />Certilicate of Occu U \:/pancy
<br />Notes Remarks, Etc.
<br />I
<br />I
<br />=
<br />=
|