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BUILDING- INSPECTOB RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS owNlrr aull,lll:L Dl:l,cAx^ rIoN
<br />I tEEby afilrm und.! p.bolry of p.rjury rh.t I m.r.nfl nom rh. Ctr Eclod l.tosc L.{,o. rh. follo*i'g '.!en l&c7031.5
<br />Busincss ad Profcsh. Cod.): Any Ciry or Coudy whEh rcquncs a [Ermir ro .onnDci, ,h.r, i'npr.v., d.mlnh or Ep.r $y
<br />{ddua. p'i',' b ik nsuajE. rl& Etlui!.s rh. applicanr ,br such p.mir ro fiL a sixn.d.rar.tunr rh.r h. or sh. B lr.Nal pus.(
<br />to rh. |tFvirons oI rhc Conreto. r l,t.nscd li* (Ch.prcr r. C.nmcrcing lirh Scri.n 7(l) ol Divirhn I ofrh. Ausi*$ ind
<br />Pof.s$trs Coilc) or rhar ht ot !h. i! q.nnr theEiion a.d th€ hasls for lhr rlLg.d ex.nrprio. Any rioLrionofS.crbn7031.5 hy rny
<br />ipplicad rorlp.mn suhj.ct (h. appliclm ro 3.ivitp.nrhyofmt mr.rhsn fiv. hundr.d dollsr ($5tx)).
<br />l. a owrcr ol rtE lrorEny, or my cmplnlet wnh {r8€s a\ rh.n sE mmpead$n. eill do E wdk ,nd lll ,ME ir mr
<br />inr.rtlal or ofi.r.rl fd sl. (Se 704-1. Busin.ss and Pmf.isioa CuL: Tlr C..kidoar l-ic.n! li, d€s id appl, to cn own.' ol
<br />rhr poPtrry wh. huil& o. iipmws th.rcq dd wlE dcs such mrt hin!.li or lE6.lf or rhtuu8h 6t or hd own.mrlo)€.s.
<br />I)r.\ided rhar su.h irr4FEftns m d hEnded oolreod lor sb. U. tF*s, tlE bnilduU q urpnrmd ii eld *{lljn oe ).{
<br />ot snpkriotr rh. oqM Buil&r lill h.rc
<br />'tE
<br />bunl.n ol pmwu rld rE or sh. Jil d buiu .r t vn6 ttE rmrtty rd rrE purlrl* or
<br />t. irof,rcrotrh. psr.dy,.m.xclusiv.lyconuurin! wirh lic.nsi conrsbftr. connruct rh. pmj.ct (Scc. ?O{.r, Busin.!1
<br />rl h'li\sion aod.: The Conr{crol\ l-ic.ns.l-!w dc\ nor lpplyb rn own.r ot I()prdy *ho brildi or ihpruvlr rh.i.dn-
<br />and who co rach Ir uch p(,j{h wnh a conrmrodn lt.({d purtr&r h rtf, conk&ror's Li..tu. bw).
<br />rllax[Bt coMtxttAra!
<br />DSCLABAILAN
<br />I h.rcby .6llh undcr p.mhy of p.rjury on. ot rh. follouinl d.clrdi)N:
<br />,/O$ *,. * *u,*,",r"
<br />"
<br />c.nirM,c orcoBc o sclr-ltrsuE ror $orlqL d,nqrEstron, 's provd.d ro, by s..tioi r7m or rh.
<br />bh.r Codc, tor rhc pcrforn4c oI rh. rdk ,or rhich rh. O.rnir b i\ucd.
<br />-l
<br />eniry rhar in ttE p.rforrum ol rh. wo ror which $ir p.rmir is isru.d, l sh l nor cnploy lny IE6on n d.y m mr
<br />$ is r. be$m:ubj.cr ro rh. M*d6'ompcNrion l.w\ ofCrlif.trii., dnd agG rh.r rrl rhould h.mr sbiu to rh.
<br />woA.r' .odrp.nsltio. provi\ioN of S..ri'n 37m ol $. lrbor Cod., I $ill, fonhwirh omdy wnh rhos pBvisiors.
<br />WARIING F,ilure ro *tu qdrlc* &np.nsrrion &Entc i\ unlrwtul. el shdll sublcq m.n\ahrq ro mru{l FenE a.J
<br />civil lin s up ro onc hundr.J rhoussnd dolliB (!l(r{r,(x,ll), in addirion ro rh..or ofcomp.ns.tion. dam3.s is provtd.d for rh.
<br />S..rion 1016 oarh. Lrhor Cod., hr.E{ and anofty's f..!.
<br />rfi,", a -zo- t-,t
<br />!J1lN!Ut-!-!]rl]1]-lLl8!.IMr!B!!IIAI
<br />I hcr.byallirmund.r p.Mlryolp.rjuryrtur I.m licdns.d undcr Fovision oI Chaptry 9 (..mmrci.g wnh Sccrinn 7m0) orrrivision l
<br />of rhc Busincs and Pmfc$ionr Code, ui my lic.nse n in tuU loN. ul .nsr
<br />c_- ,l- .t
<br />Clss Lr.G. Numb..obLor (
<br />t ^1-c -2n c"*-",* A(l 51" r [Loo 6 l-qJ
<br />CONSTRUCTION I ENDING AGI,INCY
<br />I h.Eby amrm un&r FMhy .f p.rjury ih. h.e ir ! u,nnru.rrn ltrdiry a8.ry lor rh. p.rtul]rlm. of rh. sll ti, which rh! p.mln t
<br />krucd rscc 1097. Civ C.)
<br />a!EucaNf!Esa!4110!
<br />I Mv lrmlak D.nalryolD.riuryom of rh.lollowins d(laniionr:
<br />r).mlirion Pcrmirs-Asb€{os NotificariJ! F.dcr.l R.gulirbtrs lTtrl.,1o, Pd6)
<br />R.qu ir.d lr(d of Noiilf,arrn
<br />I..nify,lu(h. f.d.ml rcgul{rions Eglnlmg $h.sros E Dv{lu. nor rpplicrbl. b rllt pnr..i
<br />-J
<br />c.nify ihar I harc qd $r1 anplication and {rrc rhlr rh. rhok infomBrion n cotrar t Ur€ ro romply *{ h dll Cny aid Coonry
<br />oilnutr.s lnd SIar. tiws ELriry ro huildnB.onnDd n. a,n h.Et'y rurtrriz. rcpr.snraiiv.i of rhi! Ciry aJrl CouNytu.trrn uFrn rh.
<br />,ltx^c nnnrk)ne,lDoEny r(, i,]N(r()n Nax)k1
<br />.*,(brra-,0-
<br />.L
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVlnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framino
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />[/asonry
<br />Pool Fence \
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />FINAL 7-Z/- 7d'/(,f,tt ^*to r
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc.
<br />Rev.08'07-2015
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<br />{1-L.)3lo ^ ?-o n**-r-t-zl
<br />IrndciiNtE'_
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