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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWi!IiR BUILDEll DEI,CARATION
<br />I hcrchy alltnr u.'.lcr pcmhy ot !.rjury thll I m excmnr liom rhc C, ra(rs Liccns. li, for rh. ftnbwnrS tc.q,n (S..7o.ll 5
<br />Bu:in.\r ann PftJfcssdn Culc): Any Ciry or Cotr ry vhkh rc'tutrcs ! Fmnr k) coniruLl. llrcr. imPrnrc' 'lcfrol*h or el.t ..v
<br />srn'.rurc, p n() r issrancc. aho rcquircs lhc lnplicant,irr \uhFmr t) hle0 sign { dltcmnr rharh.or shc i\ li.o{J pesxMl
<br />l,) lhc t'r)vnn,ns ol rhc Conhcttr'* Lrcnscd Lrw (Chtprcr 9, Con,tuNii! wilh Sccrion ?lm ot Diviqion I ol rhc llurinc$ dd
<br />Pmtis{ons Conc ) or thxr hcorshc is c\cmpl rhcElion 3Jxl rh. hans Lr rhc alkgcdc\.nflion Anv vi,,lari,nol StrtD70ll5 bvanv
<br />rpphur li,r r Fmrir nrhjccls lhc anplrcad n, a vil lcn.lry ot nor morc rhan fivc hundrcJ dollm (5500 )
<br />l. !s owncrotrhc I,1 lxny or nry enfl,yecs wilh wrg.s 3\ tht'r v,lc .onrl]cnerion. *ill d0 rh. *drk dd lh (Bi@ i\ ior
<br />inrcftLJ or.fl.rcd tar salc (S&.70.14. Bu\ncs dJ Polcstions aillcr'l hc Conrracttr's LNnsc La* doc\ lor {fly o an owncrol
<br />rhc onlllcny wh, tuills or ih[fr,rcs rltren. n] wh) dcs suc[ urrl. nimrclror hcrellor rhs'ush hr dr h.r own cnllovce!.
<br />pR,r .J rh.r such impn'EnFnl! !r m,l ilrc,rlcJ o..ficnl lbr qlc Il, howcvci rhc hil'liry or impbvcmm is soll sirhin !,nc ycr
<br />ol.onrl)Lrir rh.O*n$ Au,Ucr wrllhrvc rhc $u.Jcn olpnriry rha ht or shc Jil,n l i0 or imnn'lc rhc fn,Fny fu rh. puF* oi
<br />-L
<br />$ owncr or rhc pNpcny. .!n €(hsiv.ly cdntr.hS wrh liensJ q,nk&n)n b onstru.l lhc 0o]ccr iS* 70411. Businc\\
<br />and Pulssirn CoJ.: Thc Cohkdoa! Lic.nsc L.* dE! noi aplly k a,i oencr ol ptoFrr, who builds or imptoves lhcr.on
<br />anJ who L\rnrra.h lor su.n FoJ.crr wirh r contn tonolic.nscd purulnr ro rhc cunlr..kx's Licnrc ljw)
<br />_Lmcrcnpr unJcr Sc(r
<br />!48(E8lllor!fE!lar!a!
<br />TIECLARATTON
<br />I hcEhy {litn un,lcr Fnalry.rpcriuryonc ollhc ri,lb*i.3 dcclarrri(,s:
<br />I havc nwill minra'n dCcnillc . dl C.nsenlnr Sclf-ln\orc lor wdtkcs conlEnsdi(n,. ri |)n)lidcd iirr hv Sc.rirn 1700 dl rhc
<br />l]t$r Codc, brlh. pcrtumanc.ofrhc work tor whichrhc pcmir is i\st.'l
<br />* i,avc an,r wirr nramarn work.n coot nsanoo in.urakc. Ns rcquaRl t'y S&t o. .tIro or thc tihor c:odc. rur ihe pcrfomc of
<br />rhc krk ror whah rhislcmir ix h$..1. My woikcH omF.nrrti,n insur.t$ clrid ,dl tIlty numbq {e:
<br />r-fl t(ork, a ra o? (? -oo /-,,t',"", q. I U/'ro
<br />I ccflitylhal inlncrertormnccorlhc wo* lM whrhlhtrPcrmn is rsucd,I shrll nor cmlldy .ny t'.Nn ,n .nv mrEr
<br />$ *tub.com biccr ro thc woltcF onp.nqrioi l.ws or Cnl orni.. and asEe rhrr lf I shouil hcdw suniar h th.
<br />M)&ds.onDcnsat()ntrovisionsofS..rion]700oflhcbhtrOxjc,IdEll.fdnhwirhdmplywirhrlx,{povrnonr.
<br />IVARNING: I'ailur ro *cm sork.r' cnnp.n{tion covcEgc is lnl.wtul, rnJ sh,ll :tbicr an .nrloyrr b 5iniftl l'enlras atul
<br />civil nncl up to om lrutulrc! rhousand JdUs ($10o.0o0). i6 rJdrion k) rhc con orcomFflsriiur, danuscs,r !tuvid.d nn rhe
<br />Sc.rbn 1076 or rhc llbr Co!c. hlcrcsr and atomy. tb$.
<br />>(""o'2e
<br />Dgcla8arlo!
<br />I hcEby.flnm undci Fhalry ol p.rJury rhtl I am liq.,l un,l$ l,tvkionotChaprcr I (.lrhmruine wilh Sdb.7m0) d'Divi\ion l
<br />oi lhe Blsi'rcs !.'l Porcsions CoJc, {rl my liccnr n h tull ,oft ,,,1 ctiel
<br />K**"."o
<br />[t*Prt-..t,d ^-lo7o4la
<br />CONSTRUCTIoN LENDINI; A(JFNCY
<br />I h.rchy .litm unds lroall, oi p.rjury rhd lhcrc n r d,Nhrli,n lenJing rgcncy flr ihc Pcrlotucc or th. work fu *hic,r rht rm 6
<br />i\stcd (Scc. 1097, Civ. C.)
<br />anJ Counrytu cnlo uFlnlh.
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Rool Sheathino
<br />Shear Wall
<br />Framino /zgza Z- (.sn + /lcr3
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certif
<br />FINAL /-rc uu 2- t7,+,4A'2D
<br />Certificate ol Occupancy
<br />Notes, Remarks, Etc.
<br />:-.
<br />Sublloor/VenVl nsulation
<br />Lm.lfl \ AJJt\
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<br />AITIICAILDECIIB^IIAN
<br />I lEn:b, alrm undcr pcnalr, ol tcrjury oN or lhc bll,win8 dahrarbns:
<br />D.mlnion Pcrmih-Ash.sro\ Noiilic,rn,n F.dcral Rqu,rlions (Tnt 40. Pd6)
<br />R.qtrNd l.rrcrof Nniliution
<br />Lcdifyrh.rth.lcncrrlrcAularioh ns.rdinS lshcsl.s rcn$vd rc nor arrtl'c.hlcro lhis P!+cr
<br />!h.rc nrnroncJ ,tup.ny ntr u(trcli('n
<br />^,., t l</*o
<br />IfT
<br />=
<br />I
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