|
BUILDING- INSPECTOB RECORD
<br />SITE-WORK ID/SIG.COMMENTS OWNER AUII,DER DEI,(:ARATION
<br />I hcrchy rififln utrd., p.nahy ol trrjury rl l n crcnpr rtu'n rtu C.ntNron- Li.cn* bp L. rhc rollowina rcasn (Scc.?{rll.s
<br />Bu\nu\ r.d Pn,fcs\ion Codc) An, Ciiy or Counry which rcquirc\ r pcnnil lo coinrud. nlrcr. nnprclt. dclfrrli\h nr rcNr rn)
<br />drucruc- prior ro irs issuarce. oho rcquircs rhc uplranr lor such |fnnn ro illc . siEtrcd $o'cmni rhar hc or she n lic.nscd purqmr
<br />to rhc nmvhiotrs of rhc Contacror's Li.cnscd Laq (Ch,prcr 9. Connncn.rg wth sccriotr 7ux) of Divhion I of rhc Ausirc$ ilrr
<br />P ds!n,ns G'dc) or Ih!r hco!sh. h cxcnrpr lhcrcfromand lhc h$is r'or rhc !llc8cd crcnrpliur AnyviohrnD.tselli.i70.115hrsny
<br />lj)plicrNnxdpchnirsubjchrhc.Dplicrtrrt,s.ivilrrcDrlryoltrormorcrhflnrivchundftddolltrn($500)
<br />-1.
<br />Bs owrcr of rhc pmtEny- or niy crnployrcs Nnh wr8cs as rlfn vnc .ompetrs,rion. will do ttE work { lhcsrrurure i\ mr
<br />imcdlsl or oflcrcd for elc (Sr 70,1J. Bu\inc$ md Prcfcsions Codcr'lhc Conrrdols l,icc.se liw does nor lpply t, ano*ncr or
<br />rhcnmFny Nho huilds or in{,m!cs rh.B)n.onl ph d(6 $.h fr,r* hinsclr or hcMlf.r rhmugh hir or hq own cnTk'ycc\.
<br />Dovidcd rMr such inl,sv.nEnt m mr i, .ni.d .r.tfcrd irn eE lf. lswmr, ilr bdiUiiB .i in{n*tnxd n $h wiihin onc )ra
<br />or..nplciio.. rrE Owner Buiut, $ill naw rhc hodcn ot pmvin8 th,l he or shc dil nol blild or impoE rtc pmFry ror rh. puqr,* or
<br />t
<br />I.nsosirr.lrhrIm,pcd!,rtr,crclu\ivclyconrrrdingsnhli.rn\cJ.oirR.ttr\hcon{Bcrrhct(I.crlSc.7(x,1.Bu{c$
<br />rn sho conr.tu\tor \uchrx,i.r\*irhr(i,irrcl{,(9li.c'N.,lru{iun ni rhl(r,im.trn s l,i.cn{ l-aw)
<br />lrtrrcxc )pr u dfSc.r B & PC lnrrhis rcx\nl
<br />Dore O*ner:
<br />woRKFRS. (:(rMiFrt.SATntN
<br />Dtscl,AAAIlA!
<br />I hcrcbyamirnundcrpemltyoipcrjuryorcoirhclolloairAdNl .rionsl
<br />btxn C c. ri,rlhc ncrtbanatreol'rhc work I qhi.h rhc lEtrd is h\ucd.
<br />IhJvrsnd,illnEinllinwortcrrconDcnsrlninnsurarcc.$rcquncdhyScclionlTmotrhcli6.rCod..lorrhcnrrontunrc.l
<br />ihc Nor[ lir whichrhh pennir is tsued My *o!kcr' .ompen$tion iNurrrcc.aricr and policy n!n,tcrrc:
<br />(:;
<br />()
<br />-l
<br />ccnily rhlr in llE pcrlornnrcc oflhc *ork tur shich rhl\ tcnnir n isnEd. I stull nor cnrpl,)y, ry pcrs)n in an, 'mnmr\) s k, hc(mr \uh]cd t, rhc lorkc'\ .rDpcn\rrim Lss olCrlinmir. rml rlmc rhrr ifl \lmul(lh.dint \thl..r k, rhc
<br />sorkcn con,pcnsxrion pnvi\i{,ns ofSccrio.3T(X).fthc hhor (ftlc.l\hall. f.nh*iih conDly *irh r)n,* povi\i.ns
<br />IIARNiNC l{lur k, rcur. *orkrri conrp.dlrrn,n cokrxgr i\ rtrb*tu|. rnd \hall \ubll.r ,r rnrdny$ ro di,ni,rl Jictrrlrt! rd
<br />.ivrl lnrc\ up k, o c hutrdrcd rh.u\rtrd dollrF tslu). X)). inrJdirn n)rl[.o{of trsrrtun. drtru8cs as Drovidcd li)r rhc
<br />ir{crci rnd om}'s fcc\
<br />x"'",tf
<br />IhcrcbynlftnuM.rpcnrlryoffcr)uryrh l nd li..nerl uMcr tiovni(, r.lChnlrcr 9(.onnNmire wirh Sc.lion 7O0O) oI Dirision l
<br />of rhc Bu\incss !.d Profcsnnr Codc. Md ny liccisc is i',Iull lorcc r.,icffccr.
<br />Y -3-l q
<br />I hrrcby al,tnrundcr pcnally oipcrjury rtur rhcrc h ! cotrnruclnr hndiry u8cmy I{n rhc pcrld.nu'{c ofihc work fo. qhich rhis lcnnir is
<br />hsucd (Scc :lLre7. Civ C.l
<br />dIPLIQINfIIEI;IIEAIIQN
<br />I llnby dnmunddr pcnrlry ofI'.fjury otr. ofihc h,lbrin8 dcclrrri(n's:
<br />D. rlin{ Pcmi( Ashc{os Norillcrn'n FtdcralRcErhri{n (-l'irlc10. Prn6)
<br />RcquncdLdrr.rof N.rilic otr
<br />I ccdilyrhrrrhc fftlcralrc8ulJri,)nirErnling rdEdo\rrrrrlrrt nor rpnli.rhlc b rhnJn{,io.r
<br />I ccnify rhd I hrvc ftad rhis rptlidiDn oJri nrrc rhd rlMlrrrc informik,n s cotrNr I aBrd ro omply wirh all Ciry and Counly
<br />ordi.rn..s and Srrre Lrws rchring ro bxilding .on{ocrio( ud hcrcb} adrhor+ ftlk\cnrrr'!c( otrhs Cir, dd Couorylo cnlq uF)nlhc*:x:W.^". -'U*
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Rool Sheathinq 'l\rr\r9 ,a,^aq(fr Ert''e',,, t *T<' Qar',)r.,t'
<br />NfVb.4^+,
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It/lasonry
<br />Pool Fence
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil
<br />FINAL 1121/tg 4D,/'/))
<br />Certilicate ol Occu pancy /
<br />Notes Remarks, Etc
<br />DATE
<br />Erection Pads
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<br />T-Bar
<br />t-nI q
<br />--l
<br />=
|