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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUII.DER DI:I,CARATION
<br />I hcr.hy rffirm uidEr p.Mlry {)f Frjury rhar , m crcmpi fmn rh. Conr&hra Li..ns. Ir* for rhc lollosin8 rci\on (Scc ?nlll.5
<br />trusircs rrxl PRnc$ior Cdc) Any Cily or County rhf,h rcqunrs r F.irnir ro con(rucl- ancr. imprctr, dc.hlirh or rcnin ,iJ"
<br />sflcturr. priff ro irs is\drncc. ako rcquncs rhc +rltsnr f.r \kh Frmn h fib a silncn drcmn( rhrl hc or shc h liccnqt pursld
<br />ro rrr polnion\ oi rnc Conrncroi! l-iccnEd ljw (Chaprcr 9- Commemin8 sirh sc.rion 7ffn ot Divkion I ofrhc Susincsl.nd
<br />Profcsion\Codc)orrhnrh.orrltncx.nplrhcrcfio,ndrhcha\kf.trrh.rlk8cdcrcnDrn'n.Anyviokr,onofsario!?oll^5hytrtry'
<br />eppli.r for a lcrmir {rbrcca thc eflicrnl to a civil pcnrhy or nor ntrc thm fivc hundrcdd.llars(S500)
<br />l. r\ own.r .f rhc poltny, o ny c pk')rcs sirh srgcs ^ r hcn {n. rofiNn\.ridr, sill do rh. q (,* n,n lh. (nrrurc n nor
<br />itrrctrdL\l o.ollircd lor *'k (Sa 70l,l, Busirc$ ird Profcssionr C(xlc Thc (inrracrnis l-i.cn!c L.* docs nor arply t' an rwmr oI
<br />rhc tmp.dy tr lx, hnild\ or i'npturs rt[tun. tld $lb doc\ such No hi'nscllorh.^.lforrlttuuthhnorhcrostrc'nploycc\.
<br />pn,vnhd rhkr s'ch i'.nn)v{rnls rm nor i' cnd.rl or oltcE-(] for rt li. ho\crcr. rhr hr il(linE or inpRrc'*trr h srld wfhin ,,nc le.tr
<br />olconDLrirr rrf, owtro Build.r sillhivc thc budcn orrovi,lA rrd hc or dr dil nol huiklor inlnmrc lhc lnpcny for rhc rrF{ ol
<br />_l- $.sncr.irltr nl'|rny. {nrcrch'sncly.onrading sirh lcctrscd coDnr.l \rocotr!n,.r rh. nmjccr (Scc 7(144. Btr\i"rll
<br />itr,l fh)fcssi Codc: l,trC. krtr's Liccn\c Lrs docs r t,tlyk,r osf6 ol l)n)|[rty s h. hnrlds or irprcvcs rhcrc. .
<br />rnd *ho conrr&lr Tor !'.h J,F r.ck wirha (inxmcrdtO li.(r\c,lpur$xnr r,rhr(q rrdir'\ l.i.cns Lxs)
<br />I r rr\crrl! f(ler Sr.rtr
<br />Drle: ()*n€.:
<br />\YORKERS' ('I)lli Pf,NSATIlI,\
<br />DECLAIAIION
<br />I hcrchy rfinm trndcr Emlly.lpcrruryonc ofrhc folloNim dcclirilions:
<br />-l
<br />havc a will mintrin a Ceniicarc ol Cooscnr ro Scll Insurc for \ ort(i cn.pcnrdion. as pmlidcd rd by s(rion l7m ol rhc
<br />hbor O)dc. f.r rh. li.rformmc of th. (olk lorwhi.h rh. p.rnrir is irsucd
<br />-lha\cr
<br />*illmrinurinsorkc6comnc0slrioninslrnncc.!\rcqutcdhySc.tion.lT(x)olrhcljhorA)d.,fdrl[nr,nnr(R.f
<br />rlf, $ork tur q hich rhir lloir is is\ud M y sor[.B con,Fn\!ri(,, in\rr u .micr ltl lx)li]" u $.r ac
<br />, c.nirylhrl h rhc |xrlornrm.ol lhc sork r.r whi.hlhis D.rn( is isarc(l.l sh ll nor cnrnloyany pcson i'r riy rnncr
<br />\, s!b hL{oN suhjcrr k, rlt $(,kcs c.'npcnsdn'n L,wi ofCxlibrnir, niil rB'cc rhd il l shotrld hc.oN suijcd ro thc
<br />w.ik.n' drfrp.nsariortnrvilionlofSeri.i lTO0.frh. t-abrC. r., \hrll. Lr r[sirh conllly silh rhos Dmrnionr
<br />WARNIN(;] I'rilur. tu $ur. workcs .omFns.rion corctugc i\ utrhwful. Md \hrll nrhrccr m cmplo)cr ro aihin l Ftrrlrtc aid
<br />.ivil finc( trI ro.m htrMm{l rh.uland dollitr (slur.(Xl)). ir.ddirioDr rhc con oi conDcnsilion. darnqes !\ p(,viddd for r,t
<br />sdion:1076.lrhc L,h, c.dc. inrcrc{ and
<br />,.,.,-9 l'"lzclg o
<br />I hcrcLy!fin undcr pcnalryofFrjury rhai I am lien€d udcr povision olChrrrd 9(.ummmr! rnh soriotr ?lr(D) ofDivkn,n l
<br />oi lnc Bu\nEs md Pmfc$i('.s Codc. nnd my lic.nr n ir lull lorcc ml clfccr
<br />( o I z-z-.1 <t
<br />9f r e /t -"*"."4
<br />IIINSIBUEIIQNIINIrIN!;JIGI,I.II
<br />isu.d rsc. .1097. Ci! C )
<br />APzuCANLDEII.AAAII!]N
<br />I hcr.$y 0fiim undcr lcnalry otlcrjury one orrnc foUowins d(hrurins:
<br />Dcm,lirion Pcnnils.Ashcnos Nolilication frdcralRc!ul.rions(_tirlc.l0. Prn6)
<br />-Rcquncd
<br />l.llcr oI Nolilicolhn
<br />l..nilyrh rhc t dfiilrcgu rotrrrcgardine rsh.{or rctrF\rlrre not lnflicrbL ro rhn pnjccr
<br />-l.cnillrnd
<br />I htrvc r.rd ihi\ lpDlicari{nr rxl{aicirur rMxti)!. idni,nxri(nr i\cufu.r lrgrfro.onrdywih0llCirrxndi,rtry
<br />oftliMnccs {ftlShrc r-r$\ rcldin8 lo huilding connruclion. ald hcrchy Nrln,i/c rcprc{drrrivr\ r)trhi! ciryand (ounly nr cnrcr urn, rhc
<br />rlnrc nrnrirron |x,l)d,r! lnr n\|r(irnrfd
<br />A--.,..-.J--- *,"
<br />SARDO:::;:::::;:j'tt -<<:e.Gz
<br />s/rolzol*.
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsulation
<br />Rool Sheathing
<br />Shear Wall /a^
<br />Framing k.Wt)
<br />lnsulalion/Ene rgy
<br />Dryw4{V,V$d
<br />Ext./[n'j. Latr t-4-ty k.wtr"\t
<br />Brown Coat L/
<br />l\/ aso n ry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />/^\
<br />FINAL t^-r--Y kv/!4J
<br />Certificate of Occu anc
<br />Notes Remarks, Etc.
<br />Erection Pads
<br />$-2J-,
<br />Pool Fence
<br />Flood Zone Certif .
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