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BUILDING- INSPECTOB RECORD
<br />- SITE-WoRK ID/SIG.COMMENTS OWNER BUII,DER DELCARATION
<br />I hly.by .iftrft undcr Fnally or pcrjury that I o cxcmpt iiom lh. Co ra.roB' La..s tlw ror lh. rollowrB reahn (5&.70]1 5
<br />Busncss aLl Ptut ssxt Grle): Any Cir, or Coun(, vni.h Equics o Fmt to con{E.r. olts. imnrcvc. rlcmlish or rctrd uy
<br />slnclurc. prior to ils issuak!, also r.qlircs lhc apphdt tirr such p.mir ro frh . siercd st,t mnt $.( h. or sh i! lic.tr*d tssudr
<br />t, rh. prtvl\ .s ot 0r Conr.&ktr s Lnrnsetl La* (Chaplcr 9, Commrein3 with S(tion ?(()0 ol Division -1 of lhr Busimss and
<br />Profcssbns Cc{.) or rh.r h. or sh. is cxcmFr rh.rcfton inJ rh. bash for rhc alkBcd .x.n roo An, violarbn oi Seiitr 7011.5 by an}
<br />appLca.r n, a pcmr sobjftk rhc apdicanl ro r cilil rEMhy of nor ma than lile hundEd doll.rs (5500).
<br />_1, ag owftr ot fi. pbp.dy, or hy enploy*s *irh sag€s A rhct $E conFnsalion, wiu !o ttF ,Wk a tlE slruture is Dt
<br />ii. rcd or dfi@J for eL (Sd.7044, BusiBs and Pnfc$ions Cod€: Th. Conln rois LiccnE La* dcs nor apdy to m oq*r ol
<br />lhc fotEny wh. buius o. ,n{mB llrR,.. a'] who iIB suh krt hin\clf oi h6clf or rhmrgh hii or hr osn cnployccs,
<br />ovilcd lhar sx.h imp,!@.rsm fr, inr.*ldl oroffdll tor sL lr. b.ew( tlt boiliDs or in{hkftnr is eUsnhinorc )s
<br />oi cotr{,lelion, llE OwF Bur!.r ril haE tnc tdo ol prus8 lh{ h. or shc dd mt bo,]d or iiqnov. th poFny ror ft pu{r,s of
<br />I.asowncrofrhcpro!.ry,.m.x.lnsivclycontra.tinSwnhli*.s.d.ortadoBroonsttuc{rhclro,.rr{S.c'70,14.Bon"c$
<br />.Bl PFl6sion Codc: Thc Conra.lois Li.cns kw d*r not .ptly ro .n ovncr of fop.ny wto htrilds o. idtiov.s rhcrcon.
<br />,hd who.onlr&lsiorslchprorelssithaConEaclo,ls)li.r€driuGuantlorhcConlra.toisLiccnscL!*).
<br />-l
<br />an3i.npi unJcr Se.rio
<br />Datc- Os
<br />lq[dE!5:tsurEls ]Io!
<br />!Ee!4-8Ar!0!
<br />I h.rcby alnm under pcmlyol F-rlury.nc olrhc rnllo*ins ,l&laraxon\:
<br />_l h.!c arj *iU mi.rain a Ccnilicalc ot Consnt ro Scrln$rc for *orkqr onFnsali.4 as lrorilcd for by S(trn r70o Dr rhc
<br />kbor Gxlc. ,br rhc pcdomncc ol lhe worL lor vhiih t& lcrDt n hsucd.
<br />-l
<br />havc and 8,ll mnlar *orkc6- compc.s.tnn in$raNc, .s rcqulql b, S&lion l?0O of lhc kbor C:odc. frtr Ibc J'crforlr1Bc6?
<br />dE srk tor ,hrh tnis Fmil is issu{n. My vorkcs comFns.lion insuran c cMicr anJ policy numbcr dcl
<br />crrrr f 4t ,ap/ 9
<br />*,.*. ADq >t I ?3a-.3 o) 5-I
<br />_I.cnify thit m rh. p.rforronc. ofrh. work for *hich rhi\ p.mi 6 nilij, I shall Nl.mdoy.ny !.^on in ony manNr
<br />s slo b..om $bj.cl lo lh. hrkds comFMrion laws oacaliroDD. aftl asree rhar ill slx,ru hccom subicl brtE
<br />uorksl clmrcnsatiotr pDvnions ol S&lion 1700 of lhc llhor Cotlc, I sh,ll. ronh*nh conFly qnh tho$ ptuvision!
<br />WARNING: l,ailurc ro s...uc wlrkcs comFnsarioo .ovca{c is u qtul. Md shrll subrcd e mtbyf to dim,l ltelra5 dd
<br />ciyil l_ocs ut Io orE hurdrcl rhousrnd dollrs (Sj00.GJ0). in rddnon 7,rf-damlcs A dvilcd ftr rh.
<br />bh, Cotlc. Dicicsr rnJ , otry r
<br />I,-l {ffi-
<br />t,..n..r i iiiiicr.olo v L.',mmn(,np . in s(hn 'rurr qr Dtrsn,n rI hcnhy rltm trn'lcr pcrohyol Frjury lhal I am
<br />c-49 .*. . l,bYs>5l,/-Z---:--tEl+r K---r--T
<br />coNsrRUCnoN rE[,{DtNc acENCY
<br />I hcEb, arm un,lcr Fmlty ol pcrjury lh.l lhse is 0 coNtru(lbn ht(lDC agcNy ror lh. Itcrrolllec of rhc work lor whah rhis Fmir Ls
<br />issucd (Se. 109?. CN. c.).
<br />A9IUCAILDECLA8AI&N
<br />I hsdry atrm lals rienally oi Frjur, om oI $e nllbvins delaralions:
<br />D.mLrion P.mns Asb.{oi Ndol,catio. Fcd.rrl Rcgularion! (Tnh 41, Pd6)
<br />_Rcqunen kG, of NdifErion
<br />_l .cc riy rhar rhc ieleral rcEularFns Esddin8 astEslos rcmral c nor atdnabk ro rhn I'ro]cd
<br />Y:r.d rrhaIh,w rc.d rhir applrcrton .Jrl n,c rhar th. abr fo,mr$n 6 conccr I agre b contly wnh ,I Ciry and Counry
<br />,s rlaxne ro buildins(ond hcEhy aurhorizc rr,rc$ntalivcs oilhis City o.J Counly ro cntr upnrtE
<br />ahov. mntii)El F)pcny tu irslEcrion
<br />Applift nl or Ag€nl Sigmlure
<br />I
<br />Or* 2 I
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlasonry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
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<br />FINAL 1-Z-$*7\A"lrlr0)
<br />Certificate of Occu anc
<br />Notes, Remarks, Etc.
<br />DATE
<br />Forms/Steel/Holdowns
<br />Pool Fence
<br />of th. Bt\iEss and Prcfesions Co!e, n my liccns n in fiill forc anJ cfiNt.
<br />lr.,ld \ ,\l,ltrs:_
<br />fT-
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