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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE COMMENTS OWNER BUII,DER DEI]'ARATION
<br />I bd.by amnn undr FrIy oa pejury tbat I m €rcmpr fiom the Conttdo6' Li.er$ li* lo.lhe lollovins r.M. (sd.70ll 5
<br />Busin6s Md Prolsion Codc) Any City or Counly which r.qui,6 a tEnil lo @nntud, all6, nnprove &nolish or Ep.t y
<br />slrudue rio, to irs isuan ., also requir6 rhc applicd tor .uch ,onir ro 61. a sig..d statdml dEl he or sh. h licc6.d psuer
<br />to the prcvisions ot the Conticroas Licenscd ljv (Chaprs 9. Connocinr vith Sdrion 7000 oa Divisio. I oathr Busins ud
<br />Proaesioro Cod.) or rhal h. or sh. is.r.npr rhd.nom md $. ba3i, aor th. alles.d.rdrFion Ary violalion ofscclion 70ll.t by a.y
<br />aDnlr(dd ro, a Im subKuthc @rhcanl ro ao\rlDenalrl oltror mcr.rhu,trc hundr.d dolld(i<00)V
<br />,/ \ 6 owno ofih. pmrd). or m) €mnlo)e6 \irh wid6 s rh.ir sl. comp.Mrrcn. trrll.h t\.sort ed thc nlrl(@ 6 not
<br />,lnlqxH or ofldcd lor sl. (Sa.704,1. B6in6 od PmfsioN Cod€ Th€ conracior's Lic@ Lrw do6 not .pply b s oMd ol
<br />rhc ptuDdy Nho borldr or inpo6 thd@n, and who do6 such wo& hidrcll or hNlf or rhrouSh his or hd owD anploy6.
<br />poliddl rhBr such iml'ovffls e. nol inrod.d or oafs.d aor $! I[ how6,q. rh. trilding or trqrc@r b $ld wirhin onr ]s
<br />or moplcrion. $c O\sd ooilld vill havc lhc b{.do of provins rll{l te or slE did nor llild or ihFovc th. pibpdy aDr fi. purFs ol
<br />l. soMdoffi.propdy, m.rcl$iv.l, .onlra(ing trirh li.G.d cont0cro*lo onn d the proj€cl (Se. ?Lt14. B6in6
<br />,nd Psbsion Cod. The c.ntrcioa s Liccosc l,av do6 nor opply to e ownr o apropdly who buil& or ihprovG rhdon.
<br />and who co.rra* aorsuch Projdu wnh a Coirmcro(, licftcd pusw io rh.Conrradois Lic€e L€v).
<br />I. €xe,npl undd SNr
<br />-"' 1J-/vt lt
<br />I h€rcby ailrm undq Fnaltyolpqluryoncofthe follo$in8 ddleatioB
<br />lh.v€edNillnDnnainaCerlifical.ofconsdtlosclf-lBur.lorwort.Bconrp.nsalion,cpoid.dforbySdion3T00ollh€
<br />tnbo! Cod.. fo. rh. pdfonnance ofrh. $ or[ aor wh i.h rh. Fnrit is isu.d
<br />_l have and *ill mai ain{ork.acodp€nsarbniNurance,6r.qunedbySalFnlT00olrh.tnborCode,aorlh.tdfomanceof
<br />rhe $orl aor which lhis lEmir is ,sucd. My workds' comp€Narion insur cc can6 ed Dolicy nurnbd tu
<br />Il cd,0 rh.t u rhe pslo.man(c orrh. Nort ior \hrh rhis psnil is issucd. I slEll nol otrphy dy p.en i,r anl mdn.r
<br /><.arohdom.sLbJe"^,hcso,ld'coi1pctua'^nla$r.fcal'lomd.Mdarrmrha'illsh^uLdbA^m.sbjdrrorhc
<br />$0*6' .omp.@rion pmvi.io6 of sdion 1700 ol rh. l4or Codc, I shall. lonhsnh comply $irh rho* provisions
<br />TVARNINC: r{ilur.lo sue {ortc compssalion corru. is unhvtul. tud shall subj<l 6 drployd lo oi,ntEl poEhi6 dd
<br />.ivil lin6 up lo one hundred thoBtud dou6 ($100,000), ir .ddiiion to lh. cosl orcoo ion. ddoalcs 6 prorid.d ior rh.
<br />scclio. .1076 oilhe tib.r Code. inrad dd anomcy s t6
<br />I hftby afiiln u.dr pdalty of Fjury thd I an li.a*d mdd FDliriob,tr f ChaflE 9 (commocin8 Nith Saiion 7000) ol DiYision 3
<br />of rhe Bsins dd Pror6io6 Cod., a.d ny lic.e is in tull lbr.. dd eII..r.
<br />Li.cBcClN: t.i..di.Nu'nb.r
<br />calslxllclIa!1[Bl1llc-dcEl(:x
<br />I hcrcby afiimundd penaltyofp€rjurythat lh@ G a coNtruclion lddins.socy aorlh€ p.rlom c. or$cvorl frr $hich rhi. Fdn b
<br />issu€d (S( 1097, Civ C.).
<br />ASIUCANLDICIAAAUOX
<br />I netby allm undd paahy oa pdjuy on oflh. aollo$irs d6Lr.rioa:
<br />Ddnolnion PmnsAlb.ros Norilicarion F.ddal R.lubrio.s (Tillc 40, Pan6)
<br />Rquirc{ Ldrs or Norifierion
<br />2{:r .o, ir} rt'u, ,t'. i"a. ot .s,huob ,cssd'ns 6b6,o( rmovar a c n4 apprrabr€ b rhs pDrd
<br />I.dirrrhd I nnl. red $is applicar
<br />ordinan.B sd sratc Lr\vs nlarinS lo bui
<br />ahovc ftnlio..d prepdly for inspedion
<br />i()n d srarc rh.! rhc ahr c inri)n .rnr is .oner l aEero.o lfl]\n[ rll (-nr itrd (iiunrt
<br />lding coBttu rio., ed h@ly aurhoriz. rq,srarive of rhis cnt md co$tlr\t)plic. i o. Ascnl Sipniru,c
<br />,..,U"" ""-",,,Ur,,r<
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framin s
<br />lnsu latio n/E ne rg y
<br />Dryivall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />A/zz //z;--'r^//xt )
<br />Certificate of Occu n
<br />Not marks, Etc
<br />n
<br />Urrl AuzAn<.tt--
<br />ID/SIG.
<br />T-Bar
<br />Flood Zone Certif.
<br />FINAL ^-, al/o</tX
<br />T 4p>=LL6rS'*
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