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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DTI-CARATION
<br />I hcrcby 0iirm undcr n Mlly of p€,iury rhar I !m cx.nDr fmrn rhe ContacroN Licch\. Lrw ror rh. rt Lsin8 rcawo (Scc 7011.5
<br />llnsinc$ and Profcs\ion Codc): try City or Cl)udy which rcquircs r t iinil ro onslflcl. rhcr nnprolc. d.ml$h r rcNn iny
<br />!ru.turc. prhro ns r$uanc.,0l$ rcituircs rhe applic nr ln such lcmilb rilci sis,td nsr.ntnr rh h.orshc n liccntd puruur
<br />r) rhc Ini,vi\t,G ol Ilr Co.rnci(tr\ Lic.trs.d ta* (Chr $ 9. Co nncNinS wilh Sccrion 7(X)0 of Divkion .l .l thc BusiDcs trtrd
<br />PmLs\ions codc)orrhar hcorshc iscxcnq thcrcfiom.nd lhc hNt l.r rhc lllcBcd dcnFrion AnyvidarionofScdionT0:ll5hylny
<br />appliconr rorapcnnir suhj(ls rtc applicxil tr rcivilrcnrlryofnor morc rhxn lrv. hundicd dollos($sur)
<br />l. r\ owmr or rhc pnrlEny, or my cmpblccs wilh srScs rs itu solccotrpcn\rlion. *illd. rh.w,fkmllhcslndu n ml
<br />i crdcd or onircd ltr $lc ( Scc '7014. Busincs md h ofc\stDs Codc 'l hr Conrr&ktr\ tj.cnt Lrw dms mr .nrly ro an owtur ol
<br />rh. pn,Iicny who builds or imln,s\ rlr6n. ,r1 wli) rnrs such sod{ hinsclr or hcrslf or rhrcugh his or her o*n .nttbytcs,
<br />Iirovidcd rh.r $,.h nn8)vcnr.rs dc ,or inl.ndcd oi oiLrcd f.r slc. li ln,wvcr. lh. huillin8 or impn,!.nEnr ir i,ld wirhi. onc )qr
<br />oa.onirl.tion.rhcO*..r Buiuo qill havc rhchodctrorfi.vnElharh.orsh.did trorhuild.ri nove dc F)pcny fd inc purliMof
<br />-1.rso*ncrolrh.lropcny.rDcrrlusivclycofirdinBwirhlir.\r.oMncrtrsroc.nnrucllhcpnil.cl(Scc7olj.Bunncssand ll|r,fcsi C.dc Thc Conrmtol s l-ic.n* l,.u d.$ nor rmly ro ao owncr oi poP.ny r io hu ild\ or inpn,vc( rhcrcon.
<br />rnd qho contm.ls ld such proj.ch wirh! Conrmcro(s) liccnscd punua n,rhcC.nka.ror'r l-i.cnr trw).
<br />lr cxc rtrr .rScdrotr .ll &P( larrhi\rcN,,
<br />Dnte: O*mr.
<br />woRKERS', ColtlPi'NSA n{)N
<br />DECI/&IIO!
<br />I hcrchy tr,liarundcr pcnrlryoiFrjur} one oilh. n,lbwinE dcchrari,xr:
<br />I ha\. Md s ill nrinrrir r Ccnifcrrc of Conscnt h Scll- INnrc lor wor [cr' conDcnsur i{]n. rs prcvidcd tur by Str nI l7(x) or rft
<br />lf,tx, C,xlc. f(n rhr p.rfonnd.cofrhc wor* for which rhd p.rnin is i\\ucd
<br />l hn\ c .fld will nrid n wor&crr conDcnsil ion insumrcc. r\ rcqu ircd hy Sftr i,,n ]7m of ihc L$or Codc. lor rhc ncrior mNc of
<br />Myw.rkcra compctrsirion i'Ntr,xfc..rtricr xl li'li.ynu rhcr arc:Fup D3 ,>_ /*/>
<br />Icc ify rhrl n, rh. p.rrodr o nt rhr *ork fd slri(h rhl\ Ilcnnir h n{rcd.l \hnllnol.nrDl,ryrny pcno idanyNanncr
<br />\) rs b hc.o r \uhjcct kr rhc workd s .onDcrsrh.n lrss ui Crlil(trnii. lnd agrcc ihrr if I rhouhl tr.o r \uhrccr ro rhc
<br />wolk.(.o.Fn\rn lmvisn,ns ol Scd is :lT0O ol rhc Lrbr Conc. l shrll tunh*irh m rdy *irh r hos rrovisiors
<br />IVARNINC: l,ailurs ro sccu'c *orkcr .ompcnlari,)i ..r.r!sc ls u l sful. trd shall srbjcci in ctrlPl.'rr ro dninJl ltnrlris r d
<br />.nil ljrr$ up kr onc hunnEd rlDu\rtrJ dolhr\ lSllD.(xxr)- ir &liliinr k, rhc .or 01.'Npcf(rrior. anng.\ a\ f(nnl.d nn rhc
<br />s$ri,in llr76.lrhc lrlrn (ixlc nnrrc!xDnrrttrn.vrlir!-D-/?'/G: nnrrr*^'V--7
<br />DECI,AIAIIO!
<br />I hcrcby alfifln u dcr pcnrxy of Pcrjury lhal l rm liensn undcr Imlhion ol Clrapr.t I (ommn.ing w h Scclhn ?(xD) oi l)ivi\n,n -l
<br />ol lhr Bo{incss $d PoL$ionr Codc, ,nd my lic.ns r in full ftrLr und cll(l
<br />o^"/L
<br />c32
<br />.qONSIAUCIIONIEIDINCAADN1;I
<br />I hcrcby.liinn uMct Fnuhyofpcrjury rh{r rhclc h a $nsrrucri(nr Lndi'ra trlcn.y lor rlt pcrf.nnm.c olthc work ftn *hich rhi\ frn,ir i\
<br />i\\ocd rS( :1097. Civ. C )
<br />APPI I(]ANT DECI ARA I(IN
<br />I lratt)y trflim rndcr pcnalr, olFrjrry oic ol rlr tulk,win! dNlnrarors:
<br />Dcnn'liri{nr l,crnrirs Ash-sox Norificdrn rcdcrri RrBul ri(in\ (Iirlc 40. Prn6)
<br />Rcquncn I rucrof Norificdi{nr
<br />lcA v rhr rh.l.d.rilFgullri.n' EFodrtrF J\hc{.. 'crar!rrr n.rrmlx'ahlc ru rhF,,n,Fr.
<br />-ZI ccnrl y rhnr I hrvc rcnd rhr utJnlk rr tr,n srrl {urc rh, rhc ,hr\r inrorml ion is corcr I lsre ro condy wnh du Ciry and Coutrl,
<br />ordinanes and Sralc liws ehrin! ro buildihg .on{fl.rdn. &xl hcEbylurkrizc rcprcc rlivcsolrhhCiryandCounlrrocnlcru['onIhc
<br />rtbvc nrnli,nrd pn)pcny ftr iNpc.ri{,,
<br />Appli(!nl or lg.nl Si*n,turu X
<br />.1Fcmrire€ nonre lpdtrtl: )L C///27<2 6 t/-19
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />Subf loor/VenVlnsulation lt I
<br />Roof Sheathing I 'rflP/)l Mvru{
<br />Shear Wall
<br />Framinq
<br />lnsulalion/Ener sv
<br />D rywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />N/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />FINAL 1- L-/B JJcf"l >Gv)
<br />Certiticate of Occupancy
<br />Notes , Remarks, Etc.
<br />-+
<br />Forms/Steel/Holdowns
<br />SLAB Floor
<br />tt
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