|
BUILDING- INSPECTOR RECORD
<br />COMMENTSDATESITE-WORK
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf looriVent/lnsulation
<br />Roof Sheathi
<br />Shear Wall
<br />Frami
<br />lnsulation/Ene
<br />wallD
<br />Ext./lnt. Lath
<br />Brown Coat
<br />I\,4ason r
<br />Pool Fence
<br />T-Bar
<br />Handic R
<br />Final ReDeu rt
<br />rtEnineer Final Re
<br />Flood Zone Certif .
<br />6FINAL
<br />Certilicate of Occu a
<br />Notes Remarks Etc.
<br />Ihcrchyr'rnnund6pc.,llyofpdrjuryrh0llrmcrc.PrirornrhcCotrtrdoNl'iL!'\ctivrbrrhclollosinerc'rn(S,ec70'll5
<br />Itusincss rnd Pmrcssion Codc) Any Cil, or counry whi.h rcqun \ I Frmit k, .otrnru.1. ax$, nnProu' d'mlGh or rp3n M!
<br />{oclulc.Fliorloilsisnlk-^c.ahorcquircslh.(pPli(rtrlf.fsuch|..mrilblllcl\isncdsaicnEnllhdhorsheili...\cdpur{uanl
<br />ro thc pn;rcions of rhc conrrerots Liccnsd uw (chaplcr 9, comnrrcir! *irh scction 7rx)o oI Dili\ion ] otlhe 8u\in$s and
<br />prrtession\codc)orrhrl hcorshc tcxcorp rh.nrionrnnd rhcbasis lorlhc ru.scdcxcmPrion A.tviolali.n.lscdn'n70ll5byony
<br />lprlicanr ro. a pcrsir sub.i..c Ihc rlrplicanr roa.ivilfcn!hyol not nmrcrhri nvc hundtcd doll'r (S5U)'
<br />-l-
<br />as owncr ul rhc po!.n!, or my cn[loyc.\ wirh wuAcs !\ rhcn s,b conP..\d tun. *ill do rlf, work ald rh' nrutm is tu'
<br />i,cdoroilqcdlitrelc(SE.TiX4.Burincsslndltf.$ionsCodc:Th.Corrockn\Li'cnsel-adocsnolulplyb'n'wncrof
<br />rhc DoFny *h builG or i'ntiovcs rlEsnr- ud who d.ts such lolk hinNcllor hcncliir rhtodsh his r hcr own cmllovee\'
<br />g,*aot ,tu *.r, inFoEnxnk m Rr i, cndci .r olTcrcd for *h Il ho$c1tr. rh. hiklin8 6r ir{mrcnxnr is $ld *irhin uic }s
<br />;rdnrylclion. ih.Owir suius {illhavc rlE burdcn or F,vinA rhal hc o! shc did tror hUild or nq'orc rhc lmBiv for rrr Pulx)scor
<br />-1.
<br />N .wncr .r rhc preJEny. !m crclusivcl, conra.rirlB Nir h licn{d .onlrrctn! t' 'on(rucr
<br />rlt !rcj'cl (Ss 70''l Brincs
<br />,,ra pmrssbn O,a., irri conarcl,tr s l-i.ctrsc Low docs not nl,r lv n, e. ow r ol fmpenv sho buil(h or irhlrovc\ rh'rcon'
<br />and *ho.onlncrslorruchnreicch,nhac(tninrn)(gliccn$dpurulllrorhcco ractr's Li'cnsc liw)
<br />O11 NEIT DUII-DDK I'IiI,('AIL\'I'IoN
<br />-l
<br />a,ncxcnru undcr s..tn,
<br />woR(FIts' c(tNTPENSATI(tN
<br />PECLAXAIION
<br />I hercbylrnnundq lcnaxy olpsjury onc orrh. folloqins dcclr iotrs
<br />-!n0!candwillminrsinacerlific'lcofcoos.ntlosclf'lnurcforworkcr..anlp.trstrtion.Nplovidcdlb!byscctionlTlx)oflh.Lhor C.dc, lbr rhe p..lo..Bncc or !h. wort f.r {hth rhc pdil:il is hrn.d
<br />-lharcandPillmnlr3inworksconPcnrarioni.mmc.arr.quircdbvsc'ri'n3?Ol)ofrhcr?borCodclor$cPcrr'nanccoflhc work tuwhichrhkFmn is issurd. MyworicB comF..drio. insutBncc clEicr and Fli'v numbcr e':
<br />9qk Erv'rc.l
<br />R
<br />tinJF''i Na,rc:
<br />,h,vc nEnriotrrd pmp.ny io. iNp..r
<br />q).\\358\-?C
<br />lr)re
<br />-l
<br />ccnilyrh0r in'hc Pcrfor@,tc ollhc wo ror shich rhn F.nrir is issued- I shrll nol enPlov 'nv ,Enu inin,nonrc'
<br />s(usm hccmr uticcim rhc workc^ co'nl).nsnrion lnNs ofc.liforniL ond,grcc rhnr ilt should b€{o'E suhitl Io rhc
<br />srrkcn comFnsaiioi li{,vnions ofsc.rion l?uj ollhc l,h, Codc.l rtull. ronhwnhcomllv wilh llnr€ ptovnionr
<br />WARNING: FailuE ro Ecuc woikcK clnpcnsarion coveEsc is lnhwful. and sh'll ruhjccr an 'nDlo)et ro di'inal ltnahis md
<br />civil finc\ ut' ro onc hlnJrcd lhousond dol;m Moo-(){)ol in.ddirion lo rh..osl olcomp'ns'lior ddm'8cs rs onrvil"l lhr rhc
<br />S.crion.1076 ofrh.litnrcd.. inrcrcsr and anormy s fNs
<br />u^", 1lZ5/1u.,> Approtr,: @W7
<br />I rcl Ns9l) cotrtrR cTclf,
<br />DEIIdMIITN
<br />Ihcrcbynifirm!.d.rp.ndryolPcrjulylhalla'nlien{dundg!m!i\ionofchlPlcr9(conlmn(inSrnhscclionTtDo)nfl)ivi\ion]
<br />ol rh. aDsirEss and Pr,rcssions Codc. srd nyliccns ir in fullrorcc.ndcftNr
<br />CONSTIII'CTIoN I IINDIN(; (;IiN(:Y
<br />lhcrchya'firdUnd$,)cnallyofljrjurylhollncdtacondmclionlcndilsoBcncyfulhcrrfon][nccollhcsoAlorshichlhis'crmnis
<br />i\.ndl {S( ]007 Civ. C.).
<br />A}IUCANI.DECIABAII!}N
<br />t hR$y rnim und.r Fn.hy ol r.rjury om of rhe t,llowing dslatur ionsl
<br />Dcd.lnion Pcrmils Aib.\los Nolificorion Fcdcral Rcsuhrnrns (Tille 40. Pd6)
<br />-Rcqun.d
<br />Lxttcr of N.til$tion
<br />-l
<br />cenify ihar rhc lcdcElregxlrrions rcBudins *h.sos rcm)vrldrc not opPlkablc to Ihis Pmrc''
<br />-l
<br />ccdiry lhal I lEvc rqd rht 0prltari.n ,ild ssrc rhll lhc $ovc intunurion is conccr I n8e lo otPlv wifinll Cnv d Cou'rv
<br />Iu.orcc" -a srur" t_o"..r"rini io buitding con(ruclion. rnd rrrcbyolrhoriz. rcFcsnrdrivcs (,irhis chy otrd couoryio ctrler uF,n rh.
<br />/\mliLotrr or Axr.l signnl',rr
<br />n"*,r"" ."." , Onr,,, Zl A.lhrlltty'l
<br />rEtrT
<br />l)t^ llk
<br />lr- r ro.i L
<br />tin'ri(.\Cdrc.s
|