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BUILDING- INSPECTOR RECORD
<br />SITE-WORK ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Su bf loor/VenVlnsu lation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq b-zt-lg \Uotr lr
<br />lnsulation/Eneroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL
<br />Certificate of Occupancy
<br />Notes, Remarks, Elc.
<br />OWNER'UILDER DEI,CARATION
<br />I hcrcl'y !l6m undcr Fnalry (,r pcrdry rhrr I dh crcnnr ft,d rh. contrrors Liccnsc L.q tor lhc folbsins r.a*. (s.. 701 1 5
<br />ao\in.s\ ind Profcsion Cod.lr Any Cily or Counly shi.h Equtcs. lcflnir Io conslrud. trlru.. imrfl,vc. &mlishir rcrot.ny
<br />ndcrurc,Imrb irs issumcc. llso Ejukcs rhr applicant lorsuch pernril ro filca \i!i.d { .nf,trr lh.' h.or shc is licenscd puFulnl
<br />b rh. rbvhions .r rh. Conti.roas t-iccnscd t1w lch.tr$ 9, conanc.cinB wirh Scclion 7Oq) ol Oilhn,n I or rhc Busirr$ anil
<br />Pior'c$i(,n\Cod.)orrhar hcorsh. hercmpl rhc.earomond rh.tush ior lhcalkEcdcicnprioi AiyvidrtionulscclbnT0ll.5by,ny
<br />appliconr rbr n lErnrir suh]cclsrhc apnlicanr ro rcivilpcnaxroinor tutrc rhd rivc hutrd.cd dollam {$5u)).
<br />L a\ owkr ol rh. !tul.ny. or ny cnDl.rrcs wnh w4.s,r rhct slc comrcn\urnn,. will do rhc sork,nd rhc {n.Nrc n mt
<br />iNcndLil ijr ofilrcd lor slc (Sc ?0.1.1, tsu\nrs rnd Piof.s\ions Codc Thc Contr.rof s Li.cn{ tjw drcs not lpply to !n orrcr of
<br />rhd l,n)tidy wh. buildr or in{rovcs rhcmn. d (k) dcs {ch wod( hnnsclf or hcrclt or l hmugh hh or ner own cnployccs.
<br />pnvidcd rhor such ilrlnrcrcmnh!rcmt i.rcndcdoroficEd Io! srlc li lo$cvc!, rhc huiLliu or impowftm is v,Ll rirhin .m )tr
<br />of.onfLriotr rh. Osfti Buiklcr willhlvc rhc brdcn ufpn,vine rh:[ h] di shc did nor build or irprovc $c pnIEly lor llrc t]uqx,s oa
<br />_1.!sowncrolrhepnpcny,amcrclurively.otacriigsirhlicctrs.d.onta($r.con(ruclrhctmr$l(Scc?0.14.Bu.inc*
<br />andlh,tussanCdclhcContra.lolsLicc.scl,owdocsnor0rplyloa.own.rolpror.drwhobuildsornnprovcsrhcrcon.
<br />and who .o.hck r(r roch F.jc.rs wirh a ct hdon r liei\.d rur\urtrt o rhc Conracttr s Liccne lrwl
<br />IJ'nrr( rtr !nd.r Sc.ri,)n .ll &PC ii,rrhi\ !r$,
<br />t)rle: Owm.
<br />wonxrgs' (r)ltrPrNATl(N
<br />DIELAIAIIQN
<br />I hcrchy !rfi rnr!ndcr p.nrlry.rl).rjury.nc otrhc rollownr8 dc.l,r,rions:
<br />-l
<br />nnrc lnd sillnRinrsin rCcnlil..lcofConsctrrro Sclf-ln\urc lnr qorkcrr compcn$rion. a\ pmvirled fitrbySNrn,nITLUof11[
<br />tihr Culc. rar lhc F-rioflDnce ol rhc lvork ror shich rhc pcnnir i\ isu.d
<br />lhavcand willnBinrrin workcri co'npcnsition innmncc..s rcquircdbySc.rion:171x)oirhcliborCod..forrhcNrforntrNcol
<br />rhc work for whichrhis p.mrir is hsuLn My$orkcn ,np.ns{li.n insurmcc crtricr mdpli.ynu $crd
<br />-lccnily
<br />rhar in rhe Frformkc ofrhc work ld whkh rhi\ p.rmir is nsucd. I shnll nol cnr0loy lny pctron i. nny nrtrmr
<br />qr ns ro bcsnr \ubj..t ro thc workdlconDctr$lion hls ol Cllilornh- rnd xsm rh.r irl shuld tEcom suh]c( ro rhc
<br />wolkcK.onv*NdtionI)nvi{ionsofScclion:lTl]oollhcLatryC,d.,lshrll.ro'rhairh.onrDlywithrh.ePmvhions
<br />wARNiNc: lraihrt b {.ur *ork$ ompctrsrl$n.ovcrrgc rs unhqful. ind \h l \lhjccr an cmpk,tcr Io dirtutrl lrnrlri.s 0trd
<br />.ivil nn$ up t, otrc hundrcd thouslnd dollon (llfiJ.(x)o). in lddirion t' rhc coi.r.onrFnsalon. dam.Bcs as Prcvidcd lor rhc
<br />Scdi,nr:1076olrh. t
<br />'txtr
<br />Cbdc, ir crc(end ro.rcy \ fcc(
<br />w., 5 lZ- I L( - Areri@,. D<.,d$-
<br />LIIIiNJ.!:DJANIAACIA&
<br />lllcLaEAlloN
<br />0'- ?.. {t->
<br />I hurcby aflirm uftLr l).nalrt oiFrjury lhlr I im liensd undcr rovtion or'Ch4'dr 9 (.onnirncitrg {irh Salnn ?O(n) ofDivi\n,n:l
<br />of lhe Busines md Ps,fc*i.ns Codd. dd ny li.cnsc ilh lull a,trcc,ndcriccl
<br />-fo r.{ r t
<br />4/21LX- c-,.*". i?".-* ?,"(t,\;r)
<br />lQNrBllqIIl)NIllDlN(irliENl:I
<br />I hcrcby dfllnn und$ p.Mlty ol tErjuryrhrl lhcrc is0 con(rucrion knlinssE n.y r(r rh. dnr rn.c olrhc work Lr$hichrht Fm n
<br />n\D.d (Src 1097. Civ (' )
<br />AIIUIAILDECLABAIIOX
<br />I h.Rby diinn undcr pcmll, o, pcrjur, ooc otrh. folln$nrg ilc.lrrriotrt
<br />Dcmlni.n P.nnih Arbc{os Noiificoliotr l{dcr0l Resuhlbns ('lilb.$. Pan6)
<br />R.qtrnd l{rr.r of Norilicrrknl
<br />_lLTniiyrhnr rhc lcdcrrlrrcxl,ri({N ftg,rdin8 r$r{.srcmovrl.rc norrpplicahlcl. rhG pn,lect
<br />l.eniftrhir lhrlc rcrd rln! eplrdn dDd{rr.rh rhc db\c intuflndiotr is.onccr lxgr&k'..nll)lywirh0llCiryrnd(outlt
<br />oklinan.c\ md Srarc Irtr\ tulrritrg k, buiklirB.on{ru.iion. drl hcrciyaulhoriTc rcprc\.nrari!cr l,fihx Ciry iid C.unryb cntrr u|ht rhc
<br />ihovc mnriorcd fr.pcny ior insp.dtun
<br />,\ppllcarl .r AA.nl SlaNruro.
<br />*m r.em'n€(prinr): l{-f /rf
<br />n Sl+:.lta
<br />IDATE
<br />trndcis AJdc*
<br />Brown Coat
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