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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNOR BUILDER DI]LCARA'IION
<br />I hcr.by alfinn undcr pcnalry of pcrjurr rhzr I an eremrr riom rhc contacloF l-i(oc lls ror rhc rollo{ins,ca\on lsccToll !
<br />Busine$ ..d Profcr\in Cod.) Any Ciry.r Counry whi.h r.qutcs { pcrnir ti L$n(fl.t. .lrcr. inryovc- dcmli$ .r NNt nnv
<br />ntucfurc. pri{,io ir\ isud..c. a]so rcquircsrhc rptlic$r ri, \uch!.'nirlo lilc r si8.cd slolcn*nl ltar heorshc is liccnscd punulnl.
<br />ro rhc pmlisions of lhc Grrrucktr\ Li.cnscd ljw (Ch'l)rff 9. Comrrcncing wiih S..rion 70(x) of Divniot :l of rhc Busin.s rtrd
<br />Pntcssion\ Codc)or rhd hcorshc tcrcnrfl rhcrcliorond rhc hasis nrrhcall.E.d.rcm[i(,n Anyvt,larion.rscdi.trT(].ll5byany'
<br />.mli.. f rpcnnil subjcclsrhc appli.lnr u d.ivil Fnrlrr.rnor n$rcrlrn livc hundrc dolldn($5(x))
<br />-1.
<br />as o*ncr ofrhc !tut ny. (r mycmployccs sirh sa3$ !s lncn $h.. lrnQri()n. willd. rhc iuk arxl rtr {tu18 t tror
<br />i,ncndcd.rollcndlorMlcISN1)44,Busi',.s nd I'or.ssinrs codc lhcC. rocrois l-ici{ b* do.s nol 0IP!y h M o*trcr ul
<br />ihc pR'pcny *ho hild\ or i'nn',^rs rhcNn.0.d sho des {rh $o* hnnsclfor hc^.ltor rhmuCh hi\ or k' oRn.'nfloycc\'
<br />fl ovnbd rh \u.h imnrertmnk rc nor inr. lnt or ofidd ntr sk lt h'!ou. rh. huitli'rg or inry.\tn:fl is srH wirhin ,
<br />'nc Jtr
<br />of.o {lcrir. lh. Owncr Buillcr rill h,vc rlt hurd.n of pn'vi'rS rh tE or shc dil frr build or inrlovc rhc PNFny f( rhc Puqnr ol
<br />l. as o*trcr ofthc,'iopcay. $.crclusivdly.o rtriiS wirh li.ctr{d coffado6 ro ('nntud rtr l)n,j.d (Sc. 7l!t'1. Bd\inls
<br />aftl lbfcsshn Codcr 'l'hc Cotrrrrclol s l,i.cnsc l,n* do$ mr npplr k, rn os crofpronc yqhohuil or nnprorcs rhcrc.n-
<br />rnd *ho conrrlcls for such roj..rl qith r conrnNon I lic.tr{d plru,trl b rhc conrNtr s Liccns l isi
<br />-l
<br />amcxcmpr lndcr Secr
<br />W0RKFRY CONIPIJNSATIoN
<br />I,T1CLA.SAII!]N
<br />I hcrcby 0llirmundcr Fmlry ol p.rjort otu orrhc lollownrg lc.lmlioDs:
<br />-l
<br />nlvc afrlwil!nEiorbin iccnificar.ofconsc hSclflnsurclo!$o cr' conp..krion. 0s ImvidcditrhrSdclion.lT00ofrhc
<br />tihor Cod€.lbrlhc pcrio.nDncc.rthc work lorwhichthc ncrnrir n hslcd
<br />I lrvc.nd will nrrnr.in qor[cri compcnsnrtn, in\u.lncc. x{ rcqutcdhySc.ri,)n]7(X)ofrhcLahorQ)dc,irtrrhcf.rroroun(or
<br />rhc wor* lnr shicn l[npcrmir is i$ucd My workcA .on]|xntrion inntrinccqtricr od tx,licy nu rh.ruc
<br />,E eoa
<br />-l.cnify
<br />rhar in ihc Frfonmftc ofrhc work for wlrich rhi\ t'cirnil i\ i\sdcd. I rlrll not cmnloy rny Pcroo in rny 'nMNry, * k, tE om subj..r ro lhc *ortcn'conDcnsrri{n hws ol CdliLirrid. nnd ryE lhrr irl \hoold h..o rc subi.l to rhc
<br />worr.n.onf.trsorionprclnionso,Smiion:l7U)ofrh.trhtrCodc.I\ttrll.ionh{irhconrplyrirhrh.*[ovi\i{,ns
<br />W RNIN(; Failur. (' sur. rorkcB dnp.nlition colcragc t mh(tu| rn{l n,.11 q,hict .D cmpbys t, crilninil lrnllric(r.d
<br />.n I ln,.\ np n, 'nr. hu rhous.nd dollin (Sl(xl.(xx)). in diri{'n r danEr.r rs lrovnhd Iq rhc
<br />C.tu, i' crc{md hrrrcy r ncs
<br />I hcrhy rfii,nn.dn Ntrrrryol pcrjury rhrr I am liccn*d lndcr
<br />.l rhc Bu\ii.s,nd Pi{n ssirnrCodc. d my liccnsc h ir rull
<br />ofCh4rcr 9l..ntrRnci',9 trirI Sc.rDtr 7lx[)) ol l)ni\i,r ]
<br />te -a"tr"?,
<br />?
<br />I hcrcby rmrmundc, rEoalry of p.rjuiy rld rhcre h a consldcrion lcndins lgenc, fttr rh. FrlornEncr.frhc w..k r.r shkh tht lrrmi n
<br />(srd (Se.1097. Civ. C.).
<br />AIILICANLDECIAMITAN
<br />I rla.]6y finn undcr t'.tr.lry.it'crjuryonc olrh. rolk oins dc.ldari.ns:
<br />Dcnnlirion P*nirs AstEslos Notilicarion rrdcrulRc8ularions (Tirlc 41). Pd6)
<br />RcqriEd trncr of Norifi .$itrr
<br />lr.'rl\rhrrrltl(al.rxL'.au]xrn)\r(rntrln!r.hn.\trriknrlr,.nfrr|Jnn.'Hrr)ihi\|,'1..r
<br />I ccnnyrhrr I hxv. r.lldrhi\ L't'0li.xri,ir d{n c.'rccl. I rsrc t, mnrrny wrh rll Cir
<br />.i.li'rIcs nid SrIc I-rw( ehlirg lo hDi
<br />dlnr nrn!i,)ncd nx,pcny f(r ir\r{rn
<br />\cnri,r.\ ffrhA( iryNl (in'nr
<br />Al)l)li.mt or Aaent sianalurr
<br />l,..nril.e nor€ (pnnr):
<br />()
<br />Set Backs
<br />Erection Pads
<br />[JFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsu lation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />lVasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />t
<br />FINAL 1r//11Y /?u-w I
<br />Certilicate ol Occu nc
<br />Notes, Remarks, Etc
<br />Forms/Steel/Holdowns
<br />t14
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