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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Ereclion Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Roof Shealhinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Brown Coat
<br />It/lasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certif .
<br />I
<br />FINAL l*2!+'l >,lLtl I
<br />Certilicate ol Occu n
<br />Notes, Remarks, Etc.
<br />01tNt)r 8t II t)t.R t)It( \R \ t)N E
<br />I hcrcb, nnirn u ndcr Fnahy o{ lcrjury ihar I m c{mpr fronr rh. cont&tom Li.cnsc Ln* nn rhc r'olbw g m{ ( 5(.701 1 .5
<br />Bu\inc$ ud Potc*ion Code): Any Cnt .r Counry whkh rcquncs r Faril lo con\ltocr. rlrcr. inlpn^1. d.'mlnh or rcP3n an5
<br />nto.turc. rirro irs ii\um.c, rl$ NquiEs lhc trpplicrnr lbr suchFflnilto filcusigncd st,rcnrtrr lhal l*or shc h liccn\cd Pu,\uan'
<br />ro lhc l)()vn nrs oi th€ Conrracttr\ l-i.cn{d ltrw (Chrrr.r 9- C.nnmMirg *ilh Scclion 7Nx) ol Dilisn,n I .rrhc Busirrcss and
<br />ProicssbnsCodc)or rhlr h!.r\h. hcxcmpt rhcrcliom.nd rhc h.sk ror thc 0llcscddcmprioh. a.y viol,rionorsccli,,n 71rll.5 byrny
<br />amli.rnr r(tr r l.rmir \uhr..b thc lnt'liconr lo acivilpcnrlryofnol m.c rhM fivc hundEd dollars (3500).
<br />-1.
<br />:s owmr ol rhc |r'ori(ny. (tr ny .mplolccs silh wrlcs rr rhcir solc (nnpcDsrrt'n- sill do rh. work ad thc (trtuE il mr
<br />intcndcd d o,rcftd ror sdL lsR.ro4,l. Businc$ atrd l']mlcsions (dc: -lhc C.itr.roar Licctr* Law des nor lpnly ro m o*mr of
<br />rhc nn'rdy wh' huinh or improvcs rhcmi. and who dds su.h eo& himscllor hcr\cllo! ihmu8h his or hcr own.nlPloyccs.
<br />nmvidcd rhrr sn.h inDovcnrnr N ml inrcndcd oroficEn lorsh lt ho*eKi rtr hliUnrg or inlrtukmtrl is $ld girhin,,m ,u
<br />ofonplcrion, rhc O*ncr Buiucr will hrvc rhc bunhfl ofprcvinS thil hc or shc did frn buikl or nn (Nt rhc floPcny fnt rhc IUrPo{ ot
<br />,.s\o*ncrorrhcropLny.anrcxclusivcllconrrlclirswnhlicctredcora.ro$locoo(ruclllEp(+d(s&70:14.Bu\iEs
<br />ql thf$si.trCodc'ahcContd.tnsLr.nscL.qd€snoriiplyroon.wncrorlrop.nywhobuildrorimprcvcsrhc'con.
<br />rtrd who.ont.crsfor\uchproFllswirhxC.nrhcbnrlicn{dpxNuinrrothcConrracroisl.iccn\chw)
<br />Lmcxcntr xM.r Sccti
<br />"*ffi
<br />I hcnby rflifln und.r pcMltyolncrjury onc ofllt dlowinr dtltdtrionsl
<br />lhrlcadwillnrn,irrCcnittorcofConsenrroSclttn\!rcrorwort.r{.otrrpctrs{tiotr.!srrclidcdlorhysccrh:l70Ooillrc
<br />L.rt&. C,.J-. hn rh. tdr.rnmr..nrh( qnrl lhr trhnh rhc lcrn'it '\ \.u.,1
<br />,)Clhrvc trnd q'll urnrrir worlq. co'npcn\srnn 'n.uratur. as rrquir.dbyS.rln,n:17(nolrh.l!tx,c.dc,f.rrhcpcrtormnceol
<br />rli. w.rk Lr whi.hrhis Eflnil is hsucd. M,sorlctr onlpcn\urioi insurrn.c .iricr .!xl lolicy nu.rb.t m:
<br />I /4FR ///5.(e s/lo\u( uc (t/(/ / 3)
<br />-l
<br />ccnilyrhar hrhc r.rlonmnccofrhc sork for whi.hrhi( pcnnir is i\\ucd- I\hrlln rcnlnloyrnytlcnon inr!, mrnNr
<br />n, r\h lf,conf, $bjfcr h lhc sorkcrl corlPcnslrion lne\ ofCrliturnir, triJ.!iLt rhrr ifl sholld tsoN $h,cd t, rht
<br />workcricomr.isdbnp()lirionsofSccrior3?0t)olrhclntrrCod..lrhll.lodhwirhcotrPlywirhrhosF,visi(trr\
<br />IVAkNING: Iiiilurc ro $uc s.rkcrJ comtcn\[iofl covcrngc is unh*tu|.ltui \hrll nrbi.cr an cmPloycr n, ai'ni'd trtrrhics d
<br />.iril linr\ up b om hu dl rhournd Jollrr lsloo.(x){)). ir addiri,,n b rhc .od of co
<br />4&:vt'7
<br />s-,* ,, rr,r, r ,11 r ,r,,y',,,r. ...r.,,r.rr
<br />,,,,'",'6/s//9 \pp
<br />ul']drl;l2-eoNl&!!-r9ts
<br />DECI.A8AIION
<br />I h.rhy 0rtunundcr Fnillyolpcrjuyrhur I m li6ns.d undn tmvisiotr olChorrcr 9 (conftncin! wnh Scdion 7m0) ofDivi\ion -l
<br />of rhc Blsitur\aid PmrcssiorFCodc. ood nry ltensc i\ in fu ll fixe url .fic.r.
<br />))7
<br />/g /16etf
<br />CONSIBIJqIDNIDNDIN$.{OENII
<br />I hcrchy amflnund.r p.Mlly.l pcrjury thol lhsc h a conslocrioi lcndiig 0B.mr lor ltc P.riormte orrhc work lor whi.h Ihis Frmil is
<br />isskd (Scc :1097. Civ C.).
<br />APT.I,ICAILI,IECLA8AIION
<br />I tINb, afflm utrd.r Fnrlly oI pcrjur, o@ of rh. follo*inA dLtlmr ion(l
<br />D.nblirbn PciinirsAsbc(os Norificdion Fcddml Rcgrlrriotrs (Tirlc.{}. Pfi 6)
<br />Rcqumd hrrn oiNotifrc iur
<br />-l
<br />ccnityrharrhc lcdcral r.Euldrioni ra.rdin! Nh.(os rc.Dvrl!
<br />D,t
<br />fujr(ni.y,',Jr I h,\" *,,r rh^annltrx',on mt {Jrcrh.,hc fi rc inr,
<br />nor amlicablc ro $is proj.cl.
<br />sarion k coddr I 0BrN ro ompl, airh all Cir, dConnty
<br />* PAU
<br />- ::,2;;-
<br />Ext./lnt. Lath
<br />zlPJ
<br />tind.r'.
<br />^dJr.$
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