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BUILDING- INSPECTOR RECORD
<br />SITE.WOHK DATE ID/SIG.COMMENTS OWNTR At'ILDER DELCARATX)N
<br />I hcrcby uflnm u cr pcnalry (n pcrj!ry lhat I m cxcnq, irun ihc cotrt.cbN Lic.trs Liw ld thc lollowin8 rcasr lscc.70rl 5
<br />Bustr'.s and Ptufc*bn Codc) Any Cir, .r Counry {hich rcqutcs r tx,rnil lo onslrucl. lltci inrprovc, dcm,lhh or rcltn My
<br />slrucrurc, tri.r(o irs isuncc. aho Eqnircs rhc dpplixni fff suchrcnnir ro filca stflc<l (atcmnr lfilrhcorshc is liccn\cd llculnt
<br />t, ihc Fotirions of lhc Conlrcrois Liccnsed |-3u (Chaflc. 9. Commncins wirh Scdion Trxx) .f Divisinn I ol rhc suiflu$ trntl
<br />Pmfcssions Codc) or Ihd tror(hc rcxcnDr lh.i.ft6m Md rhc hnsil forrh.alklcdcrcnDrioD. AnyriolarionofSd.rirnT0.ll5hran,
<br />rrtli.snr rdr r pcrfrn subjdslhc applicanl toa.ivilpcna[yolnor mrcrhatr nvc hutrdrd doll-s (S50o).
<br />JJt. u. n**, ni,t'" p,n1"ny. o, ,y cflrro)rs wnh w.e.s dr rhctr b..om*i\rroi. tr,r do rrr wdk,,d rh. crmrm ( hr
<br />imcnddl or oilcrcd for slc ( Ss.?(N-t. Busincs and Prerisions C*lc Thc Q)trhnctor's Li.cnk tjs docs nol apply ro !n o*kr oi
<br />rh.pmldy who buildsornn n,v$rh.en. md sho d6 s!.h sork hinsclf or hcrcll or rhFtrgh hk or her o*n cmplor.cs.
<br />providcdrhar sudh inrl(,wnEnh m frn inrcnd.i ororcrcd fin\ah li ho{Tvcr. ihc hilding or tll0mrcmnr issH wirhinonr trnr
<br />of.o,nphrion. rrr owncr Buiuer will hrle rhc hurdcn ofFovin8 rhor hc or shc did
<br />'xn
<br />h{ild or irymvc thc pmleny tor rhc purlncof
<br />I. Nosn.rrrrhcJx,rdr, rtrr.x.lusivrlt..nrJcri'rs $irh liccn\! cofrrr.lo\nr.on{rlc lBtrojccr(Scc 7044, lnNnrc\s
<br />rnd wlro c.nrradsrilru.[poic.r\uilhi(ifl(cnritti..tr\crlNr$r k,rh.C.rrr.lrtr'sl_i.ctrrti\rr
<br />I r cxc lpr utr{lcrSccri{'n_
<br />,"..,: l-1?)(
<br />I2E!IrIBA.II0!
<br />I hcrcby,fllnn utulcr pcidr,orp.rjxry on. orrhc aollorins dr.^l aliors:
<br />I hrv. drxlwill tuinrlin aCcnificarcolCon\cnrroSclllmurc hr wolkcF conrpcflqlnnr. rs [ovidcd rbr bySccr]on:l7lro.l thc
<br />ll}xtr C{nlc. fu rhc pcrfornmrcc oI th. wort lor whi.h thc pcnnir L{ n\ucd.
<br />_lhlvc nM will rdnirrrrtc^.o lf,isdirnri'rurrnr..riqrncdhySc.ri(ii.r?(xrorh.lihorCodc.fnrhcrdrxnii(or
<br />Ihc $ork tnr Lvhi(h rhr Nr trrir r\ G\ucd. M, workc - .o.rlrn\rri(n, i',srrrmc uricr idd F)liry nu lbtr re:
<br />sj,..nili rlrr itr rhc ,.rtmNrncc .t rlE $ork artr *hich rhn I.rnil i\ is\ucn. I nrll nor ctrDloy iny pc6on in lny ninncr
<br />!, r\ t, h.conrc {rh]ccl h lhc $orkcs' c.nrlcn\dn ha! or Crliln ir. nnd +rcc rharirl rh('uld bc.o,R \ubjc.r rollr
<br />*$kc conrcn\rrior t'$vnbtrs olSNtim:l7()()oflhc Lahr Codc.I rhdll, ft)dhwirh.onlply srrh rho* ttuvisidE
<br />WARNINC lirilut t, k rr. $ltrltcn .a,mpcnsrrbn colcra[c is unhwiul. ]nd shxll \uhjccr !n c'.plorr ro.ri'niml t^-nrhic\ rnd
<br />.ieil fircr ut k, or hundrc rh.usrid dollrs (SlOo.UD). in lddiri{'n h ihr ro{ ofcompcnsarn,n. da'n8c\ r\ F,vidcd nr rhc
<br />Scchor 1016 oiihc l-ntrtr Codc. ir rrc( did anonky \ racs*, - )-/f / ? ,tppri*nr, K..t4 K"d+r=,
<br />IECI,Af,AIION
<br />I hcrcby amm und., r{Mlly o{ pcrjury lhsl I n liansd undn lovnion ol Ch0prs 9 (onnEmi.s uith Sccrion 7000) .r Divi )n l
<br />ol' Ihc Busimss lnd PoL$ions Codc, ril nry liccnsc h in tull b.d and .fic.r
<br />COISIf,UIIrcIIDNDINIj.ACEN(I
<br />I hmh! afsnn uM.r l*nlhyorp.rjuryrha' rhcr is a consrtodhn lcndilrs nscnc, nr rh. Fdormin.. ofrh. *oft for which thn |rnnir is
<br />hsLed(Ss :l{r7, Civ. C )
<br />AITUCANI.DECLAXAI]AN
<br />I ltdry afim undu rcnalry ol Frjury nnc ofrhc followin8 dcchErions:
<br />Dcnr,lirion P..nih Ashc(or Norinciion Fcdcralkc8ul ions (,irlc J0.1,!n6)
<br />Rcquircd l.(cr of Nolifi clli'n
<br />.rl!$."n.r1,r',r rr'" r"a",,r,.!ur ,nn\ eadd ne sqh.{^. r'n i r.'r Jn n. i rnnr'.ih$ ro rha n,.rcr
<br />-!1r *nry,,,, t r,^","^r,ls,nnlrdr,n lnd larc rhor rhc a6ovc inrbrinnri{nr iscord.l asre r..omply wirh aU Cnyand Coniry
<br />,t6'nrn!c\ rnd Srrrc Lr{r rclsrrng rn hdilling.nn{nc,'on. a.d hcrchylurhorEr rcprcrorarivcs oarhi Cny and Counr! lo cnr$ utrln rhc
<br />rh,v. nrdi,trrd D.t).'ry liir 0\N.li(r
<br />AInlicntrr or Agcnl Sigmtum D"'" -7-lq / g
<br />*-r""*-"10r*,, X o\c,g { -Sp}g e&ij'/.1
<br />Set Backs
<br />Forms/Steel/Holdowns ) n-E (-:*D
<br />t 9a'Yt ''z&
<br />UFER Ground
<br />SLAB Floor
<br />ubfl nVlnsulatio l-v-g.-Ua{+le,-ZD u/e,+ttu/ r,t,
<br />Tl-oof SheathiiE--a ,,rfln Tn t*^*^1,fD/
<br />Shear Wall Z t:tdiR fr ,,lI^,'^,l}6)
<br />Framinq )lB)t't +.Ll^)a.-w)
<br />lnsulation/Energy l.6lzAt'ts T iln^jq^
<br />Qrywall )hi? -ii,.*\rt\tA./,:-@
<br />Ext./lnt. Lath I 0l*l(9,*^Liv,,$,^-,5.,
<br />Brown Coat I
<br />Masonry
<br />Pool Fence
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />1l5lv9 l,ri$<za n
<br />r1'lrlrlrg ,tM-)n,t4r)
<br />FINAL t l'r,rl I u-l_/ I \^ffi)Cerl ilicate of Occupancy r/r
<br />Nole s R m a t ks E t C
<br />-a l[1,/
<br />Erection Pads
<br />T-Bar
<br />Flood Zone Certil.
<br />u tX r.n"{- -
<br />Li..n{ Clrrs
<br />-l-icensc
<br />Ntnrhcr:
<br />I)3lr
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