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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE COMMENTS OWNER BUII,DER DEI,CARATION
<br />I hcrel,y allirm unJcr pcnrhy (, tcrjury rhal I am cic ,rr frcm rhc Cd tru\ Liccnsc ljw tur rh. ablk,sin! rc!$n (Scc 70-11:.
<br />A{snc$ .nd PrnasNn (iJc): Any Ciy .r Cotrnty whtrh rcqurci a Pcmlr k' rondtud. ,lrcr, imll'vc, dcrml'$ or nNn $y
<br />{ru.Itr. prun) \ ,surtrcc, rko rcqurcs rhc tntliuant iorsuchFm b lih a \ r3ned satc,Nnl rh heor\h.nlt.nt PuN.nl
<br />i' rlr rmusofls i lh. Conrrarttr's Li.n\cJ kw (Chrprcr 9. Conrmcncin! wirrr Sccrnm 7(XD of Drvisiur I ofrh. Busincs rd
<br />Pnrcsbns Co,.le)orrhrr hc or shr ( .kcnlrl thcrclronr mJ rhcl)nsis lnr lhc rllcacJ cxcnplil)n ny vidalnrnolSecrt'i ?0r15 byant.
<br />aprlrcr turxpcr.nr subjccrs rhc dlpli.anrroacrvrlFnalryoltrortrrtr thrn rivc hu.,lrciJollaF($5dr)
<br />I. as o*mr .l (hc pnrrd y. or my cnrtl')y.cs w h wilcs !s rh{ hl. (onl.n\dn'n, *ill d. rhc w'l( drl ih. {tum ( nor
<br />mrcrlc.toroll.r.'tlbr!.lc(SG...1044.Businc$an'lttl,ldsionsCod.thcC(rrr.l,r'sLi.enscl,rwJoc\n.ialllytouownerol
<br />rlEIn,p.ny wlu 6uil'l\ or in{hv.! rln sr. { who(lo.ssudh*)* h'n}cll orh.t\cltor rhx 3h hrs or hs own cm0ktyc.r.
<br />pn)v cd rh r s'(h mlsrrnrnh m r nroJcJ or oiarcd lor slh ll ho$crn, rhc blildinE or im|'t)v.rrcnl is n)ll] *ihin ,,'c ]cr
<br />ot.onddinr. rh.opncr Buildcr *illnrvc rhc huden oI I,rovmr rhar h..t drc dd rn tuilJ or iqrov. rh. Pn)Any nn Ih. Pu,Ir)s of
<br />l, as owncr oi rhc pn,F-ny, rm crrhnv.ly contacrn! wnh lrccr\cd .onhrnr i, eo.{nkr rhc tt ic.t (Scc ?()44. Ausim*
<br />an l t\tr,6!nn Codc: Thc Cu kicld s Li..nsc h* Jocs nor amly n, xn owncr ol F)o.d y *ho htilds ot rml()vcs rhctcon.
<br />rnd *ho .onrruck lnr \uch !(,J.cG wirhaCo tuet,(9lEcn$d Inr\uror brhcCnntrcrois Liccnsctiw).
<br />I rmcxc rf un,lcr Sc.l
<br />thte
<br />-
<br />o*n.
<br />lvaB[EsLEOUtENS4rqroEct Sdrr{}!
<br />I hcEhyrr'rt rn't.r t.nrlryorrdjuryoN o, thc ln&'wnr8 J&hrri,'n\:
<br />I hrvc ann willminrain r C.nittar. ofconrni b scllllnrrc lnr workcr' !1,mpcnsdx,n. as lntv*lcJ 6r byS..!ion.1?(D dfrlf,
<br />tf,txn Glj.. for thc Frlimnce ot rhc work f(tr whih rh. ,.mn i< rsucd.
<br />I tuvr r J w'llnr.inrr1n w.rkcri.onrpcnsarixr insurtrn.c, as rcqutr.J bySc(rnr lTmoi ihc l-,htrCodc, ntr rhc lcrl rmrnccoi
<br />,^ ", iB!l*-Ft , " ".PrM) q,.rlcF rm'rrNr n'i.urJtuclamq. rsrrvnurM'f
<br />-\(4tr- \.ruil
<br />I -1-z /
<br />-l.cnrfyrhrrinrh.pcnnrnlancoIrfuwortlnrwhiehrl,rn(rm
<br />*^\uc'l.lfirlln, cmtl,,yiny F^,,n in rny mrnml
<br />\t Irul{(i,m\hr!('', hcs rt.,..Jmncni'a 'latr.,,,ril'i,{{'.,.$J Nccrlr I\!,uldha"h.{'F.rr",lr'
<br />work$! uonfctrsari,n pn)!isi('n\ oi Scrri,r ]7tn ol rhc uh, Ci!l.,I dull tunhwirhcom0ly wirh llsr P('vis(,ns.
<br />WARNIN(;: fdilu(* t, {curc rork.r conpcns.ri,r covcragc ,s nlawlul, iu nrll n'hF.r J, .n[],))t r) cnnurl rmhas atul
<br />.i!il iincl ot rr on. hun'trcrl rhousrtrl doll$ (Sld).(Xx)). In 'nnli(,n h rlr (dsl oi ..m!'.ns3rn,n. JanaFc! r\ F'vi{lcd lnr rhc
<br />Scrion 1016 otrl[ Lalitr C dc. uncr$rrD
<br />l^o 2o
<br />DECIAEAIIgN
<br />IhcEbyilltn!fricrpcnalryorFrjuryrl' I.mliensdu er B,vi\ion or ch+l.r 9 (.om,rcfrins rnh Sdt,n T(xxl) ol DNnion .l
<br />ol rhc Buincs oJ Prulc$bnsCo'lc, dd mylr.ns. ii h full lorc dellc.r
<br />-\13 u,
<br />20
<br />CqNEB!SI$N!EN0IXGr$-ENCI
<br />I hcrchy dfirflhdcr pcn.lry.i !.rjNylhlrrhcrcn!con{tucrion hn lihs ag.ncy fd drc !!'dnnnsn.c ot rft qork n Bhchr[tFrmir s
<br />tn'cJ (Sc(. .l(,97. Cir. C ).
<br />AEILIIANI-UECLAAAI]A!
<br />I lrrlry sllim u nJcr p.nalty.l lxrjryonc ol rnc hln,*ing J.clrrrn)ns:
<br />Dc.nnirnr Pcnnnl^n{{ds Nolitiuari.n l:c'lerrl Rqtrhrn)ni ('Iirlc 40. Pdd6)
<br />_Rcqu rd Ix cr.l Ntiilicarbn
<br />I ccniilhllllrlc'lclalr.g0laron\Eldd,np ish.{.r rcm)vilarc nor rnlli.r$L r)rhr Pn,ler
<br />,.11uqriy rhli I hrvc roJ rhr rrnl.,r(n turl n,tc rhrlrhc llx,vc inn).mr'on il(ftd.I asN r('.omply wirh rllcnyrn,l C.unly
<br />o.dinan..\ itrlt Sr c bwrfthrinE rohuiinne..nsrruuli,r ad h.Ehy rurl$irc rcEcenrarivcs oa rhi\ Ciry rftl Counly tD cnt( uFnr rhc
<br />{tr)vc nrcnti,'n.J pnrpcny tur - t-t-Lo
<br />ADpli.atri or As.nl sixncltr
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SI-AB Floor
<br />Subf loor/VenUl nsu lation
<br />Rool Sheathing
<br />Shear Wall
<br />Framing
<br />ln su lation/Ene rqy
<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 />A
<br />FINAL //zl/;ztt.,
<br />Certilicate of Occupancy '//-/L'
<br />Notes, Remarks, Etc.
<br />ID/SIG.
<br />txnJ.i\ Nrnr
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<br />l.trJcr'. 4,1.!. -
<br />I
<br />IfI
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