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BUILDING- INSPECTOR RECOHD
<br />SITE-WORK DATE ID/SIG.OWNER NUILDER DELCARATION
<br />I h.reby rflt'n unds ltnrlry {)t F+ry rhrr I d dxrnpr In,m rhr coiLr.u^' Liccnsc hq lor lhc lbllowirs rcr{,n (SN 70ll 5
<br />Busirc* ,trd Profcs\ioi Cl)dc): Any Cny or Coutrry whi.h Btun* r Frnir to con(nrc1. allcr. improvc. dcmoli\h nr ruldn uny
<br />slruciurc. nl ior Io irs (surkc. also rcquncs lhc alplicnnt lor sucn fnnir Io filc a sirn.d {dc,tunr rhar lr o. sh.
<br />'s
<br />liccn*d Puisumr
<br />o rh. fovirhns of r)f Contrr.lofs Li.c.scd tiw l(hapt.r 9, C.nnncn.ing wirh S.diofl 7000 ol Divhn'n .] otrhc Buiinc\s !trd
<br />Pmfc$iotrsCoJc) orrharh. orshc iscxcmpt lh.rcnomr rlthrstforihcrllc3cdcxcmpri.n. Aoyvi{,lnrhiorskrk{70]l.5byrny
<br />irnlicrtrr ro!apcn.il s!hjcch lhc aprlicrnlro !civilpctrrlryofn.lnDrcrhan ti!c hundrddollnr\ ($5fi))
<br />-1.
<br />ns osrc, oi rhc I'n'pc.ry. (tr my cmnkry.cs * irh wuacs !s r[cn {,b co'nF \ari,nr, will do rhi work dxl ihc nrurm h nor
<br />n[c'r]cd orotlcrcd fG strld (Scc T0,l4, Busircss rrd Pmfcsst r\ Codc I'hcContacusLiccnscLrwdocsn.llptlyrosn.$n.rol
<br />rhc pmpcny who builds or inrp(,B rh.d4 el who des su.h work hrmsclior hc'Ellor rhrotgh his or hct orn cmPloyccs.
<br />[ovnbr rhar such inuorcnror\ @ nor inrcEhi or oficrsl iir vh lr. h,w.\e, rh. hoiklin8 or impmv.mN h sld wihin one ]qr
<br />.f..nplcrir[ rh. Owncr au,k]d will hlr rlr hurd.n nl ptuvrng rh h. or shc dd mr huitl or irqmrc $c pmpcny fo lhc J]U!F{ of
<br />l,trsownc'olrhcptutcdy,ir.rctusnrlyc.rdi'rBwirhli.cn\cd.onrr0crorroconslrucllhcpo]ccr(Sec?O44.Buvncsl
<br />md Pmltshn Codc lhcConhcrols l,ice.sc l-awdocs nor aptlyr. !oo*ocr ofpiopcny wh. build\.r rnrprovcs riercon.
<br />rnd *ho conrBchfffsuchptulcct\wirhaG,nrBct,n\)li.cnscdluiiudtrrorh.Cont rtrsLi.cnsu*l
<br />"b.("X)7'Qotr!"""",V<t@/c"\I()RI(trRs (()lIfliN5,\ l l()N
<br />I2[ClulS IION
<br />I hcr.l,y Jlltnr uflcr F-nrlry ol !.rJury oN ofrhc f,,ll,)*ing drcltrri(trr
<br />I hrvc { u ill nui'nri0 r Ctnill.nlc ol Coilcd ro S.lf.ln\urc lir \'*cr' omncn\rrion. a\ nmlidcd fu by Sccnotr l7(D . r rhc
<br />tjtxr Cfth. nn rh. Il.rfonMftc.frh. *ork n *hi.h ihc pcflnir is issuLrt
<br />I hrvc0nd wrll 0inloin sorkcrs corrpcnut oo inurrmc. !\ rcquncd h,Srcrion 170) ofrh- tihor Codc,lor rhc Pcrtinumc of
<br />rhc Nort frtrsti.hthk p.nil is hs,ol My*ork.^ conp.ns,ri,n, nr\!rrm.cnicr turl Policy numt'c. arc,
<br />CFi.r:------
<br />Policy Numbcr:-Expncs:
<br />_lc.niryrhrr lnrhc plrIni,umeol ihc *ork nr ahirhrhn plnir is asu.d,I rhrll not c,ryloylny pcrsor ir lnynuncr
<br />v, r\ b trcotu \lbjccr h rhc so*ci\' .ompctr\arir r lrwl or Cilirdnru rnd r8rcdh iil \h)uld lt\ornc \uhj.{r kr rh.
<br />workcri Lunpcnsrr i{'n pmlision\ of Sc.r im 17(x) ol Ihc hLh(tr ('(xtc. I dhll. lir thwlth c mply s ilh lh'{ nnrisnnr\
<br />WARNING I'rilure b *.urc w),kcr'c.nrF srlirnr fuv.n8c i\ unltr*tl. rnd \hrll \uhBr ,rr. rrloltr ro dinrinrlf.nrlris anl
<br />.iv1l fircs ut, ki otrc htrndrcd Ihou\a.d dollar (:ll(D.0()()r. in Jddirn t)ihcronof.o rtrtrsrriotr. d!fluscs
<br />C
<br />DECI,AIAIION
<br />I hcrcl,y rfirm u'xlcr pcnalry.l p.rjurr rhd I un liccns.rl nndcr nrovhion olCh!!lc' 9 (conwtins wirh Sc.riun 70u)) olDivirion ]
<br />ol rhc Busincs md Pmfcssions Codc. dd my lic.n\c is in full forcctukl.lltcr
<br />I-i.cnrc Chs:-
<br />Dore: Conlra.lo.:
<br />CA!flf,I]!:UANIENIIN!.A!iEN3;I
<br />I hcrcby amrmunncr poslry orrcrjdry rhd rhdd n r.oiitu.ri.i lrndin.! iBc cy k)r lhc ncrlomance otlhc Nor( ror rhi.h rhis rciinir is
<br />tsucd lsc. 109?. Civ. C.).
<br />AITUIANLI]ECLAAIIION
<br />I lxrhyrlimundcr pcnrtry olpcrlrr, onc ofrlt ftnk)winE dcclrarbn\:
<br />t)cnFlirtrn PcnnillAslEslos Norilirnri(r l-cd.rul RcruhliqN (l'nF 40. Prno
<br />R.quirci L.rl., ol Norill.alior
<br />.rdinrmcsi.d SrarcLrws rclarilr3 ro huiktingcon(rucrion- aBl h.rchIaurh,iu. rrl ollhh Ciry and Gutrry t,.nrcr u,n rh.
<br />rlbuc rnii(,rd ptuprnyf.r bs,Ecriotr!urlts\
<br />,*" . O*,\DDliutrl o, .\rctrt Siu lur.
<br />l'entritN nrnmlndd): X lfuftar
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/Vent/lnsulation
<br />Roof Shealhinq
<br />Shear Wall
<br />Framing
<br />ln su lation/E n e rqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Cenif
<br />FINAL 7.L- B J/ebh
<br />Certilicate ol Occu pancy
<br />Notes, Remarks, Elc
<br />-+
<br />COMMENTS
<br />Set Backs
<br />kndrl\ \.nr _
<br />_ L,nr'J rlrr rh. rcJ.'Jl 'rlulJn'{r.
<br />(g.rd'n!..h\ra. rc'nrJr. c n.i Jnfl'.Jl"h L,,h\ nf icrr
<br />-#"',I# ".* -. 'n,'onnrrdnnlnr{Jrc,hrl rh h,vc inrnrnuri{ is..rc.r. I rgre ro con,rry * hauc yxndLl,rmy
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