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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER AUII-DI]R DELCARATION
<br />I hcrcby ififln utulcr Nnally oi lcrjury rhd I0ncxcnpt rrorn rhc Cotrtr.l.F Li.ctrs l-r$ lbr thc nnk,wir8 rcrv,n lscc7{).ll5
<br />Bunn.\\ rnd Pn,fc\\ion C{xlc) An} Ciry or Counry shich rcquirc\ r p.nnir lo mnnrud. rlr.r. i'np(rc. dcm)lnh or q'dr in!
<br />nnrtuc. uiorro irs issur..., llso rcquncs rhc dftli.r ror s!(h Fnnirb nlc r\i8trcd ndr. Enr rhar h,.rshc ir liccnscd ptrrlur
<br />n, rhc n(ti\nn6 of rhc O,nrrr.nn \ l,iccn{d La* (ChJprcr 9. CornnEmi',g qirh S..rnnr 7(X)O .f Divni :l o, rhc llusincs\ atrd
<br />Pnnassi( \ Codr) .r rh r h. or \hc is crcnpr rhcrdriom r rh. h!\t turrh.rtlcgcd.xcn{nn,n Aiyvii,hrnr.lSccrionT0ll.5by.ny
<br />itplic0nr for a0.rmr suhjcchrlr rfrlrcrtrrro rcivil|xnilryol ior iorc rlrn livc hundrcd dollan(r500)
<br />l.a\ oqRrofrhcpn)Fny.o n!rmPby.csNirh*!B.s!srh.nsohcotr,!.n\"rion.$illdorlf,sorkarldf,n dtrrennur
<br />iNcnJ.d orofiarcd l lrlc (SN 7()1,1, Busircss rml Pn,L\tuft C,xle Thc Corkr.tr\ Li.ctrsc L.w d.cs tror dnt'l) roano*mruf
<br />rhclr)t*dy who huikkor inDn)vcs rhcro,r. Jrxl who {r\\u.hwod hnn\cllor lrr\cllorrh'oulh hi\ or hcrosncmtbycc\.
<br />nrtr idcd rhrr su.h inDro{nrnh rr. mr inrcfrlcd or .rtr\l fo' elc Il h*.$( thc hu Lldn]8 .r inDrovcnEnr h sll *irhi'r oN yca,
<br />_l.lsowno nl rhcir)ttny. rm cxclulivcly cotrrrM in8 qirh liccDscd .onrricnrs kr.rr{nEr rhc n(&rr (Scc 7(!,1. Bu\in.\r
<br />xl Pmirs$tr Cudc ThcCotrtr.rofst-i.cn\c!-audocrnor3ppl!r.,noqndofFrr). y*h. buildsor nnF)vcr rh.rcotr.
<br />rnd who conrrrcls fr suci proj.rrs wirh r O,nr!ado(s) liccn\cd ru^lmr ro, lt Conrracroi s Liccn\c l-aw)
<br />I d cxchfl und.rSccrbn
<br />]IABtrDB5]1;S!ITIINiAJ&N
<br />DICL]LBAIIA!
<br />I lrfublrrfiirnundd,f,f lrlrlpdJuryoncolihcr,,llo{i'igdcrltrrrri{nr
<br />I havc dld will ,Minrnh , Ccdin.dr. .f (inr*nr tu Sclf ln\urc litr sorkdr- .. !.nsnrioo, rs lovdL'd ntr hySccrionlT0Oolrhc
<br />trb.r Codc. forrl[Nlfonn rcofrh. work fdwhi.hrh.I,cnnn i! i\suc
<br />_l hrlc rM $illnui (in wo c6 coDF-trurion i.\mn..- rs rcquir.d tySc.ri,nr:17(xJolrhc Lrb{tCodc. f.rrh. ndrronnam. oi
<br />rhc *qk lnr qhi.h rhis |Ermil ir h\cd. My wortcrs conlrnsrri,$ irsufln.c.rnicr xnd Fni.y trutr$cr arc
<br />Iccnii!rhrr inrlr Fcrra ndn.c.frhcworkfdwhi.hrhilFnnir is is\ucd.I sh.lltror cDdoy lny p.rcn in rtry ma.ncr
<br />v, ^ ro h.conf, sri,jccr lo rhc wo,k c!s' .o rrrcnsr r i,r larr ol'Crlili,.nir od agrc r1 r il I rhorld b...trf,\ubr..r ro rht
<br />woricn'compcnsalnrnrrerisionsolSecrionlT(iroirhetrtDrCodc,l\lull.ionh$irfilr,nrlywirhrho*rovntun(
<br />WARNIN(;: Frihrc t, \c.ur. workc's c.nDctrsdriur.orcralc is unlrwlul. id rhall sub.jc.r an cnr oycr ro crinrinll pcnahics d
<br />.,vil finc( utr tr otr. hrndEd rhousrd d.lld( (3lm,O(D), in |lddIi( ro rhc.on ofconrpcns.rn,n. domiEcs ar provi{tcd iq rhc
<br />Sccrion 1076oflhc trh, C.dc, i crc(and.norrcy s fccs
<br />Drk: Applisnt:
<br />t.lcrrvsrn ttrxturrtrn
<br />DECI,IB{IIAN
<br />I hcrcby aflirn utuld lcnrkyorpcrjury rhal I rn li.ctr*l under tnrrisbn orchrpr$ 9 (.orNncinS with scclion 7r[0) otDivnion 3
<br />ol rhc Busims and Pnlcsrnrns Conc. e, nry liccn* h in tull li,r.c uxl eflirr
<br />coIsra.ljcrl()NLENullcilirtill
<br />i\lucd isc( 3097-Crv. c )
<br />I-ci(Lcr\ Aildr.\
<br />iIftU$nUiCLrAi\IlQN
<br />I tf,tuhy rlttDrufttcr J--nrtry.fJxrjury om or rhc nrtn,$in3 d.ctJrrid
<br />l).trDliriu Pcm rAshcsos No'iiicrrin l,cncrrl RcEu ir( F ll ir[,r0, I'rn6r
<br />Rcqnicd lrrrcr ol Norill.llion
<br />I Nn'li rhr rh. rcdcrxl rcEUhrion\ r!udi'r3 an{no\ rrnn\rlrrc noi $!l'.rhl. t, rIn Ir)rc.r
<br />-lccniiyrharl
<br />havc rcud rhislptli.rriona,xlnorc rhnrrh.rt$ve iriormrri{m is cotrccr laFehcon,plywirhrllcilyandc-ottrry
<br />odirrnccs rtrd Srarc bwr Ehnng to bundinS ..nrdcron. drl hcrcht {urktrizc rcprescnllrnrr,)frhh Cirylnd G,onrt k,.nrcr uBn' rlr
<br />ivc nrcnrn L:l Frpcnylnr i'rsfNrion NryJsc\.
<br />,\DDlic{ orA*rnlSi*nrlur.
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Rool Sheathinq
<br />Shear Wall
<br />Framin s
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />l\4ason ry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />fl/t't//d @teDr ,h.
<br />Certificate of Occu pancy
<br />Notes Remarks, Etc
<br />UFER Ground
<br />Subf loor/VenVl nsulation
<br />T-Bar
<br />FINAL
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