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BUILDING- INSPECTOB RECORD
<br />SITE.WORK DATE OlVNT:R I]UILDER DEI,CARATION
<br />I hcrchy rfinnr undcr p.nrlty ol lcrjury lhal I a crcnrfl lnnn rhc Co rrctn't-i..tr{ us rd thc tnllosins r$rn lsc.70:]1.5
<br />tlusin.\s rtrd Prftsion Co.lc): Any Ciry.r Couniy which rrqun.s r ttrtrrir h con{nd..ltcr. nnPmvc. dcnn,lnh.r EPdr My
<br />dflotrc, pri{, r) irs isu .c..ho rcqurcs rhc dffli.0nr r.r .h Fanir ro filc! risned nrltrftnr rhd hco.\h. i\ li.c scd lursurnr
<br />r. Ihc p(,riri{ins oi lhc Cnnlrrck, s l.icen\cd ljw (Chrpicr 9- Co ,mrnci'r! wirh s..rlon 7u[) .i Divi\iotr :1 ofuhc Bu\i'1rs rid
<br />Pn,fcr\i{,nsCodc)orrhrih(.rsllcncxcrprrhctufio'nandrhcbsi\f(trr1[(llcScdrxcrUion Antvi0hri,,norSLrrintrTl)1l5hyM,
<br />nppli.rnr t d !(mrn \ubjr.rs thc .,rtlicdnr ro r civil pcnally of mr nrc lho li!c l,dndrcd dolln* ( $5(x))
<br />_1. r\ osncrol rhcpoprny, 'rn,yc {lotcc\ siihNr8c\ r\ rh. $L.nnr|).nsrrion. *illdo lh. *ork rxl rrt {flrm n tur
<br />i, ctrdcd .rolhrcd for qlc (Se ?(},!r. 3usirrc$ and l'r.lcs rns Cnlc -lhc Contrrn'\ Liccns. L.w doc\ nor.Itly h rnotn.r ol
<br />Ihc nR,Ndy wla, build\ or i'qflJEr rlENoD- ![l sh. d,f,s uh sork hi'n\.ll.r h.r\cllo hmuSh hn or [cr owtr.mPloyccs,
<br />I'ovnhdrhrr{rhi'npmvcrnnrrcmr.frLdoroficEdlorslc.ll.horrcrcr.rr*huikling.ri'npri,vcktrristullrlhi t'n.rt.tr
<br />ol..mnLrior. rhc Oqncr Builds will hi!. rhc hrdcnor'prcvirs rh hc or \ic d il nor build or impn)vc tu ln)tsy lhr rh. puqr,r ol
<br />l. !so*,ncroiric propcny. rf,crclu\i!clycontKri'rg$irh lic. \cd.oitn ttrsk,.on(Ncr lh. nre,c.l(S.c 7O.1.l. Bu\irtc\{
<br />lh,fc\sin Cod.: Thc Contrtr-r Li.ctrsc Lnw dos tror lpfrlyro an owrcr al pn|rny sho Sdild\ or nn[ovcllhcrcon.
<br />lho .onhcrs lhr such lxiJccr\ $irh a C.nrrucrn( \) lic.n\cd Nr\urir r,rhcCotrk{.&tr's Licctrs lia)
<br />I ncrcnU trndur S..rion . B & PC lnrrhis Er*rn
<br />I)ale Oin$:
<br />lVOI{XFRS' COnIPFNSATX)i
<br />DECI.A.BAIIO!
<br />I icrchyillirD!Ddcr pcmlryolI). jDryon .f rhcn)lbsi'r! dc.l rnrn{t
<br />-lhrEinlwillmainrdnrCcninrrcofcon\cnrr.Sclfln\urctu(orkcr'compcn\ari{'n.nsprovilcdli)rbySc.ri
<br />170Oolrh.
<br />trhorConc.6rrhcpcrturnunccollicwolknn$hichrtcp.nnn i\is1uc
<br />Cr'rirr
<br />l.cnrly rhar iI rh. D.rli,flru.cc ollhc wolk lar which rhi\ pcnnir n i\\urd. I \hall nor ctrl|)loy arry pcison in af, trrnnrr
<br />$ r\rohcorE sbjcd hrhc *or[cri.o rpcnsdion hs:or(rlibirii. rnd i8ruc rhnr iil \h.ukl6.c.nt \th]..rrirhc
<br />sorlc^ con]Pctr\rrion pn)visiotr\ of Sdir l7(Xl ol tltr' L'tr{ C' c. l \hrll. n)nh\rirh .. dt wirI r lDt tnvis ion(
<br />WARNINC: I'lrlurc lo ccuR *orlc .onpcn\dion $trrrFc i\ unlnqful. n \hrll {,h].i in cnrn)vn t, si ri lNMhic( ud
<br />civil litrc\ rt h om hr'rtrcd rhotr\rid dollxrs (llfi).(Xxr.ltr rdd[iotr r. rhc co{ olronip.n\ n]i. Jatrtrlcs (s tr.vilcd tut rh.
<br />Sc.rn :l{)?(,.f rhc Lah, Codc. ir crc( .nd nrioncv s {.cs
<br />Der.: Applimnll
<br />r rcrusrn co,"lrn rr]Itrn
<br />DE(:I ARATI(IN
<br />I hcrcbyulttn udcr Fn.h, oi r.rjury rh( I m liensd undcr p(,ri\ion drchapl.r 9 icomnErcins wirh Sccrion 70fir) olDivhion 3
<br />ot rhc ausnrr\md Ptur.$i.nsCodc. lnd myli.cn€ is ir iull in.c $rl cflt.r
<br />CONSIAUCIONIINIIIIE.dGIN1;I
<br />I hcrl,y aftirnr undcr tfnallyorp.lurythal lhcrc hrlr)nslrucli,,n hndi'rsascn.y ror rhc p.rtonmncc otrhc*o rorshichrhn pcnnn is
<br />tstrcd (Scc :l(D?. Ci! C.)
<br />AITLICATIDEIIAEAIION
<br />I hc'rb.! d0nn u Mf Nnnlly of !.!ury onc ol'lhc lbllowing dcchrrrin\:
<br />Dcnrollri.n P.rnrirs Asbc{os N.rifi.{ion Fcdcfll RcBuldi(rN llitlc 40. Pnn6)
<br />-Rcquircd
<br />tdicr ot Norilratbn
<br />I.drilirllrrhcl.dcrrl(AUhriitr,\r.EIdi'igJ\h.no\'.ntr,rrlx,t.rnJ,fli.ih.n,rhi\nni..r
<br />I .cnn,v rllr I hrvc r.d thk rtplicrri.rr rod dlrc ihrr rhc xhirc itrnmuridr s.orrcl. I i!!c b.omlly with rll C[y dtrd Coutrry
<br />odifrtr(c\ tdSr.rcLrqsrhringlobtildirBcon{rcri,nrrndh.r.hyrlrhorizcrcDrcscthlivcs,)llhnCirrr Cotnry to cnrc! u},n rlE
<br />nvc nrnrn,ncd nn,I}.n, ff r:tc.ri(n purPlcs
<br />/1pDli(rnl or Ag0l SiEnnlrrc
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation I
<br />Rool Sheathinq Qlrt/rA -rWq-n
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lalh
<br />Brown Coat
<br />lVlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Ceftif
<br />I
<br />FINAL d/2./d -'r.@a n
<br />Certif icate of Occupancy
<br />Notes, Remarks, Etc
<br />ID/SIG.COMMENTS
<br />rlrsorklrqhi.hrhistf,nniririsq'.rlMr_sorkcrrcom|Itrsli(n,i'NUrrn.r!rnicr,iUnkyfunrh.rirc
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