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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framino
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />Itlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certif .
<br />t
<br />FINAL fr/zl/X z&?L
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc.
<br />OWNER AUILDER DELCARATloN
<br />I hcr.hy rlfinn rnd.r ,r rky.f pcrrury rld I rn crcmpr frcrn rhc Conrra.ros l-iccnsc lj* frn rhc f.llowin8 rca{,n lsc.1l.1l.5
<br />Bdvr... rtrJ P'nr...tr (mc An) Cir).. Coulytrl'rh rcqrtrr.J Flr r',r'{'rtu!r.Jlr...trTo\c..l(n'"rh'h'nln:n\
<br />srruclurc. prior ro ir\ issuucc. atw rcquir\ rhc lprltei fnr .uch Fntur [ | llk a .
<br />'!ncd
<br />nJcn rnr I hr hc or \h. 'aircnci- PuN r
<br />nr rlr In,li\nnN .l rlr Contmclols Liccnscd Llw (Chanlcr 9. Conhcn.ii! wirh sccrion 70(D ol Divist,n I ofrhc Bu\nr$ rid
<br />Prni$ions Cone)orthal hcorsh. iscrcmpi rh.diomaftl rhch/asis nr rhcrllcgcdcxcnrflion AnyviohrioiorSc.ronT0ll5htrtry
<br />xpplirlnr n, u pennir suhj((rh. altlicanr t, acivilpcMlryolnor nnrclhnn five hundrcddolla* (55tD).
<br />l. rs ownc. ol thc pmtEny. or nry cnDloyccs wirh wagcs N lhei. wlc conPcnsdrn,r. will do rhc wod ud rh. sulm il mr
<br />irrcrxL{l .r orlc!.d lar \alc (S( 7Ol.4, Ausincrs dnd I'rofcssnff Codcr Tlrc Contrcroi\ l-iccn\c liw docs noroPPly ro on o*ncrof
<br />rh.pnlicrly wtu hu ilds or inpi r\ rltG'n, r whod(ts\u.httrkhirsclf.rhcrcllorrhroughhko!hcrow.ctrDhyc.s.
<br />provnkd rhdr such nnlmrcnrnh m Bn i cndcn n o[ercn nn sb lt h,Ncts. rh. toiklir8 or nn0ortmnr h $h wirhi'r onc )tir
<br />ol lonj,lcrirn- rtsOwncr Bliucr sill hrv. thc bu'icn ol ptuvir! rhd hc or shc did ml buikl or imlnort rhc pmFn! lor lhc PnrInB ol
<br />I. N o*icr of rlrc lrotdy. rn cxelusircly .onrrocrira $irh li.cn\cd conh*)^ b .oNru.r lhc lroid (Scc 7()44. Au.i',rs
<br />! trotssin,Colc-lhcGn{ra.ktr'(Lr.trscLnwdocstrorit'tlyrorn.w.crolpropcny*hobuild\.rirytrcvcsrhcrcon.
<br />r wh..o.rr.r\forsuchpmFcFwnhaConrr!.ro(nli.cnrdpunumrhrhcc.nhktrsLkcn\cuwr
<br />I r rcr.drt, !tr cr Scclr
<br />"","a/Ls////
<br />I h.r.1,\ xlrtr'n trrtlu |r.trrlrj.l . \.olrh.liiLl,nv ng tl!.irr,trs
<br />I hNr :dd * ill nrinrri,r a Ccniliorc ol Conscnr lo Scll ln\urc fo' $$kcF .omFn\lrion, r\ pruvidcd lor hy St.rn lTmof rhc
<br />Iitxtr Qnlc. ror rhc Frrormh.c olthc wolk for qhth lhc pcnnil k issucd
<br />I h0vc rnd will nrinlain work.rs coDpcnsrrion instrnncc, rs quncd hyScdion:l?(xrollic llhor Codc. fot th.li.rformncc ol
<br />thc work Lrwhichlhis pcnnir is hik{ My workc6' .o.p.nsur ion insumncc clric! ud Polic, nxmhcr ucl
<br />I ccnily rhlr i'r rhc lcnnrnuNc oflhc sork ror which rhn pcflnir i\ i\sd.d, I sh llnor cmiloy.n, Er\on i'r any mrnn r
<br />sr rshbcnnrc hj(ttotu*orkr\ co'npc \rrn ir*sofcrlifitrid..nd4rccrhrillshouLlh.conf,\obi.rr.rhc
<br />Norkcr'conrpcnsnri,n,In)vhi{,n\.fSc.lid1700.lrhcLrhtrC-odc.lshrllbnh*nhcumplywihtln,*ptuvisnnrs
<br />WARNIN(: Faihrd ro $.urc workcr'corrpcnsarion ovc.lgc h unll*tu|. nnd (hnll \ublcrr dn cnrlolq ki cri.unl J)cMlli.s.nd
<br />.nil lin.\ Lf r, or honar.d rhoulrtrd d.l (1|(I|.(XXJ) nr rid{ior k, rl[ co( o nsariur. inrugcs r\ p(ridcd n)r ihc
<br />Sr.ri,),:lo7a olrlr lrhn ('({lc. i'[.rq
<br />,*,".Lft-g/l(
<br />l]lrt"lBti!!-^
<br />I hcrh, ainrnr undc! Fn,htofp.!ur! rhd I Mr liccnsd undcr t)nrisn'n ol Cl[prcr I (.onnrRirg wirh Scclior 70(x)) DfDivxntn ]
<br />of Ihc Busin.$lnd Prolc\sions Codc. and 'n! li.cn* is in hillbr.c.ndcllsl
<br />Conlruclor:
<br />C{INIISIJCIIOIILENUNCNATNqI
<br />I hcr$yrlfirnttodcr pcnalryorr.rJuryrhar rhcrc n r conslrucri)n Lndirgr8ctuy fdthu FnnnrBncc ofrhcwo f{rwhichrh$ Fnnir is
<br />hsucd (Scc 3n97. Cir C )
<br />AIIUCAITLI)ECIABAIIAN
<br />I hcrcl,y allim u ndcr rrcDahy orrcrjury otrc olrhc followirg dccIrarnn]s:
<br />Dcnmlirnrn Pcmrirs Astrnos Norificrrbi F.d.ral R.srhrionr (Tirl. t0. Pan6l
<br />-Rcquncd
<br />bllcr ol Norifi .riD
<br />I rn'1) rhr rh.f,lcJlrcEuh
<br />r ,.n
<br />'r
<br />,\, r r,,,1" ."n , r',. ,rnr
<br />oJ i trlcs JtrJ \+ L.'trs rcI'ri"r rr
<br />Jlltr' 'm ,{..rr&{.ir r{ trPcd
<br />A0plionl or AH.nt lilt.rrrrc
<br />r iotrs E-q{dins isbcslos rcmrval !E nor at'/h.blc ro rht pmicl
<br />trrion arxl narc rhnr th. ah'vc i.foflmlioo iscoml. I +re rod,nrly with 0I Cny and Counr,
<br />h, (Lr r! (on!'u.rh r. rnl rcprc\.nlxrilcs ofrhi\ ( iryrM Cotrnry ro.nrcr unotr rh.
<br />RHfr1tu/r/D*t *"G/29/Lq
<br />l1!|c". \J,1...
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