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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I herchy rrlirm undc, penalry.t Frjury rhrr I a6 lxemoi liom rh. Co.krntrr l-i.nsc ljw ror rhr rollosirS rcastr (SR.?011.5
<br />aunncss , Prorc$ion Codc): Any Cny or Counry whi.h ftqrncs r tEmir ro consrucr. altcr, iml'rovc. dcmni\h o' mnrn 3ny
<br />slru.tuc. lrior Io irs bsuance.also rcquncs lhc optlicd lorsuch Frmil lo fiLa liEtrcd idcrunr rhd h.or shc h lic.nscd N^uotrl
<br />ro Ih. fov(ions of rhi Conlmcrols Liccn*d Llw (ChlJ,tcr 9, a.nnncrcing silh Scction ?(XX) oa Divnion .l of rh. Busihcss ,trd
<br />ftolcssionsCod.).rthartrorihciserchptrhedlio'nsdrnehuskfurhdall.B.dcr.mflion.AnyvnriotrofSati,n7o:11 tbyany
<br />.pplicd rbr r trrmir snbjeN th. applic!trr to a civil pcnahyofnor rrerc rhi. fivc hundrcd dolla^ ($500)
<br />l. rs owftr of rhc pLotfny, or nry cmpkryc.s wirh wigc\ N rhdn sob .otrll)cnsd ion. sill do rh. rork &n thc dtum is nor
<br />inlmrlcd or oficrcd for sl. (Ss 7ol,l. Busircss ond Pmlcsions Codc:'lhc Conrrkn\ Lictr* tiw doc\ not opdy ro rnownd or
<br />rh€ pDpcny *ho hoildr or nrtrcb rhctun. rnd ah. des su.h worL hims.llor hcr*lfor rhn,ugh hir or hf own.nPloyccs,
<br />Fovidrdrhrr such nnrR,rcnrnts s. ml irlcnde{ uorlern hr st.li hNevcr lh. huiilins or inptuw.E hs'U*nhinom}tt
<br />of..nd.rion, rh. Osnf B ldcr uill hiw rh. t{ cn di pmvin8 rhd lL or \hc Jid fr, t iH .r nnprow rhc ,6Fny for rh. Nrfnsc ol
<br />-1.
<br />a\ o*nc!ofrh. rrcpcny. aorcxcllsivclyconrracriq wirh liccnscd contdck \k'.o nfld rhc nmJ.Yl (scc.7(I+1. au\i!.$
<br />md BDfu$iun Codci Thc Commclols Liccn* Lrw des nor rpplr ro nnosn.r ofprolEny who btildl or tnFrvc\ Ih.rmtr,
<br />lnd *ho conrrach lor such proicrs $iin ( Conrmchr( s) liccn*d punurnr r{, rhc G,.rdhk l-kcnrc L.w ).
<br />-l
<br />rDqc.rpl utrdcr Sc.lt
<br />ul)trtr[&5].crJlllDNl rIoN
<br />DI1:IA.B]IIIAN
<br />fr Irvc rnd sill0ri iir $orkcrs cornFn{rion irsuroD.c- 0! rcqutcd hySrrnrn]7mof rhc l.ltxtr Codc, f.rrhc |.rf.iinlNc oi
<br />l1ysqkcn lannptnsirion ir\Drrrcecrtris xtlx)Licynun,ltr c:
<br />0 24t8
<br />-l.cnrfy
<br />rhar i. rh. NrfonM..c oi lhc work l'or which rhis lcrnril n issucd- I shrll nor cmpbt ant lcson in any ntrtrncr
<br />s, N t, hconE ubjcd nr lhc so dicompcnsdn,n hwsorcaliromi,. Md rgrc ihd ill should h$o'E suhi.rhrhc
<br />*ollc( compe.urion lrovi\ions ofScdion lTtnofthc ljtxJr Cud.,I shan,f.dhwnh conrlly wirh thrs onvisi{,i\
<br />WAINING Failurc ro scurc rorkc( compcnsarn .ovcfl8c is unllwlnl. and shrll suh]cd sn cnrpl.r.r k, .nmiMl lrn0ltics {nd
<br />civil lincs ut b onc hundrcd rhousand dollm l$ltD.t{)o). in rnd id ro llrc co\r ol comri.nqrn,n, dx us.i rs troviled lbr lhc
<br />s6_rion .1076 ol ihc lnhor co{c. inlcrcn ,nd l'ltoirrcrt fes.
<br />Dste ADDlient:
<br />I (]i.NSFD CONTRACI(IR
<br />DS]I.AMII!]!t
<br />I h.Eby rfiirnundcr FnrlryolpcrjurylharI licenst undcr lovnion ol Chapr.r 9 (cottumins *nh sc.rion TtDo) ol Divhion l
<br />ol rh- Bu\incss ,nd Pmfcssi,rN Cod.. d nry liccDs. is ir lull lor.! and cfl6l
<br />cAv 16 \U !
<br />-" 4([vt\$ ."",
<br />c0NslBl]cIloNIINIllNc-dc[NcI
<br />I lrmhy ain6r'U( Ilcnllryorpcrjury rhd rh.rc is, c.ndrucrion lcndi.E aecNy for rhc Fcrlolmmc oithc wort io, $hkh rhis Fnnit ir
<br />hucd lsec :109?. Ci!. C ).
<br />I agN rosftply wilh rll Cilyand Counly
<br />divc\ ofrhi\ Cny and Coumy lo..tcr upon rh.
<br />gh x
<br />Set Backs
<br />Forms/51eel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />ln su lation/E ne rqy
<br />D rywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVasonry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />/"\
<br />FINAL gl2/ N 1Nt?
<br />Certificate of Occu pancy (
<br />Notes, Bemarks, Etc.
<br />Pool Fence
<br />I h.6b, affirm undfi p.oah, of r.rjury o.c of rhc following d.clrnridns:
<br />I havc arld will minrrin a ccnifi.orc of cotr*nr b sclf-l trsuic tbr workcs conrrcnsorion- us pmvidcd lor b, Secrnrn 1700 ofrltc
<br />tjh, Codc. fo, rh. I'crfort@c ot rhc work f(, which rhc Frdir G ir\ucd
<br />AIlL.ll;itNfllECLA&IIIAli
<br />I hc'$y aninn undcr ncDrlry otrtrjur, onc or rlr [.lloains.lcclrrarion\:
<br />l)cn()lirio. l,cflnirs Ash(nos Norir'icdi,u l-cJcEl Rc[ulariox ( lir]c r0. Ph6)
<br />R.qun.d lIrrcrol Norillcrlnnl
<br />..?fluqltt
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