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BUILOING- INSPECTOR RECORD
<br />SITE.WORK DATE tD/stG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads I T7>Wr ,l <-- D€ *-lD
<br />UFER Ground rt
<br />SLAB Floor
<br />Subtloor/Vent/lnsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framino
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lalh
<br />Itrlaso n ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Beq
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certif .
<br />FINAL 4 I t, ,tdrR Vx,,e ,€r)
<br />Certilicate ol Occupancy t t I ' U l
<br />Notes, Remarks, Etc.
<br />oWNtrR BUtI,DER DELC RATION
<br />I hercby allird undcr l.mlry 6r pcrjury rhd I r'n cx.mrr rmnr ttE Contmdor' Liensc li* t)r rhr rollowinS atF. lscc.70.1l.5
<br />ausi,rcss nnd Proic$dn codc): Any City or Counr] which rcquircs ! lcrnir ro connrud. alr.r. nnllovc. dcmli1h ur ^Tdt nny
<br />srrudurc. lrhr h ns ksurncc. oho rcquncs rhc 4plicanr for such Flnir ro fiL , si8ncd shl.m.t rhll hc or shc is li(n\cd rxnnmr
<br />ro rhc pmvisiotu .frhr conrr.rols Liccns.n Ljs (Choprcr 9. Onnnrcncing airh s..ri.n 7fix) of Divhion 3 of lhc Busiocs ud
<br />Pmtt$ionr Codc)orlhal hcorshc is excnrl rhcrErrcm ud rhc hisis for rh. J hgcd crcmprion AnyviolorionofSc.ri.n 7011.5 bya.y
<br />$plicfl lnr a Frnir subje.rsrh. arplicdn o,.ivilp.ialryofnor mrcihrtr 6vc hundrcddollus ( 5m).
<br />I. ,\ ownn or rhc l)mlrcny. or nry cmrloles wnh q0scs 0\ thcir sle conlncnsrrion. will do rhc qolk srkl rhc srtullE is or
<br />intcndcd or olttEn lor elc lsc 704,1. Bnsi.cs\ and Profcssn'nr Cod.: fic Crtrt!.t.r's l-i.ctr{ llw do.! nor 0pnly,o an olmr of
<br />rhc nm|x y wtn hildsor imp('rcsrhcG)n. rnd wh, d,n {rh wd( him{lf ot hcrcll or rhmugh hi! or h$ owtr rnrlovcc\-
<br />r,vidcd rh.r nrh impmrcnEff orc mt intcndc{ ., ofcEi hr {lc ll howclri rhc buildirg .r iq)torcmd t qnd wirhirt om }ur
<br />of conrllkrh.. thc Owmr Blildcr wlll h!!c rh. hod.n of l,olins rhdr h. or rhc did nor build or iflprcvc thc lmFny for rhc PUiIIM or
<br />l.a\o$Nrofrhcpm|rcny.r cr.lusvclyconrch!$irhli.cn\cd..nka.kxbcotr*u.rrh.fm](d(Scc70t1.hx'nrs
<br />rnd lhnts$nCod.'lhcConrrrrnnsl,iccnicl-rtdoc\norrtplyn,iiosturnlpro,Enysh.huil&otnnprur.llhcr..i.
<br />rnd who coirrdr(lar nrchtojc.hwilhr ('.tr|tu.to(s) h.cnscd purulnlx,rhcCi'ntJcroi\ Liccn{ Lnw)
<br />I Jm.xrtr,nr un(lcrS.cri(n
<br />Irat€ Osner
<br />wonxrmi tirmpr.,,r.s,rrtrn
<br />OICI.AI{IION
<br />I hcRbyrliir otrd.r Fnrlryofncijuryonc ofrh. folLwint d.clirdlius
<br />lhnr.atul will.uiflah r(ini,icatc.{ConEnr lo Scllln{nc nn {orkc^ co rPcNarion. r\ Providcd foriySccrn,n.lT0Oofrhc
<br />tlhr Cnd..,ar rhc tdf.mran.. ofrhr s.lk ld whi.h lh. pcrinn n issucd
<br />I havc and sillnrinhin workcrs .onlp.trsarn insumn.c.rs rcqlircd hy Srrion.lTU).t rhc tiftor Codc.lor rhc Pcrlirnunc. ol
<br />rhc*orkforwhi.hrhis|f,rnririsisnLrdMyuorkcrs$n{Ensllioninsoran.ecdicr,lPolicynumhcrm
<br />-lrnilyrlnrn,rhcp.rfoi,Mr..olrh.qorkfirqhichrhispc
<br />nir is issu.d.I shrll ort Pk,, dn! Pcrsnr in 00y tnmocr
<br />$Nr.tE..nEruhr.lrk'lhcworkcrsconrpcnslrioilrwsofcrlif nir.rn +(c rhd ill \houkl$ccont \nhJ.tr rorhc
<br />rorkcr'conDcnvfio.pDrisionsolSccrion.]7fi)ofihdlnhtrGxtc.llhrll.li haih cotrDly sirh rh,r n(,vi\n'ns.
<br />1VARNINC Frilu( (, {rurc workc6 $nlEns(tnr covcftSc n unhwfil- rnd \) ll \ubi.r .n.mfloyc. ro nininrlfcnxlrt\ md
<br />civil lin!\ uI b .n. hu.dtrl thdu\rnd
<br />Srcrion.1076 ofrhc L.kr Codc. irtcrcsl
<br />).0(X)r. ir ftldiri,,n n) rh.,l ro lJfncdi,nr. Jitrugcs ,s prri{trd nx thr
<br />v*",C)6- le - \g
<br />I hcEby 0finn unncr pcnrllyrlr^-rjur, rhri pmvti.n ol Chnfld q (com rncing wirh Srcri{nr TtxI)) of Olvis iinr l
<br />o
<br />o'. 06 - 18 ^l
<br />I herchy rtfi rmxndcr FnaxyorFrJury'h.
<br />isucd (Sa -1007. Ci! C )
<br />iN r consld.ti'n lcndins.scN, r(tr rhd n rlninrk. oirh. rork for $hich rhis pcnnir i\
<br />atgJ(aNfDl:s.aaafl1!
<br />I hor$y lnnm u Mcr rcnoll, oi pcrjury otu or rhc rollowirg dc.lmrions
<br />Dcmolitiotr Pcrnrits.Asbc(os Noriicarion Fcdcral Rcs!larions (Tirlc40, Pd6)
<br />-Rcquircd
<br />Lcllcr al N.lifi clri,r
<br />l.cn,fyrhrr rh.lad&(lrcguldions rcAirdnE rsbc{os rcnovalarc nor rpPlir$l. r. rhis Projccr
<br />inronrunr s.oncd I rarlr loconrply $irh,llCiry dtrd C.unry
<br />rtrrl$'r.tuj,.{nltrc\ol lhls ( irJ_rRlC.unrvni cirtr utx rhc
<br />^,", o6^19-lp,
<br />J€SAS c>-
<br />;/2)lt'\)
<br />Brown Coat
<br />or rhc Busirc$ ind ProfcsionsCodc, md my liccn\c i in tull fore ml rrrc.r
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