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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS (}WNER BUILDER DELCARATION
<br />I hcrchy 0mfln ul(tcr p.nalry of F.jury rhar I m cr.nDr fR,6 ih. Conra.irtra l-iccn\. lxs for rhc f('llo*ing da$n (Scc 70:ll 5
<br />Blsinc\s onl Prolcs\ion Codc): Any Cily or Coutrry which rcqtrncs r tlcrmit r. .onnfl.l. .lrcr. imlmvc. dcnBlnh or R! tr Jnt
<br />dd.rur.. pri{, h nr i\slarcc. lho rcquncs thc 0rrplicml forsu.h lEnnlt io filc i si8rcd st.tcnEnr !h!t lEor shc n liccnsd puruant,
<br />to lhc !relirions oi rh. Conk0.ror's Licc.*d tjw (Ctuprcr 9. ComftkinE airh Ssdnr. 7m0 of Divhion .l ol ihc aurin.\s and
<br />Prufcs\n,ns Gdc) or lhrr hcorshc iscxcmpl lhc.clrcmlnd rhcbnsn lb.ihc rllcgcd cxcmDlion Anyviol0tiotrolSectidr?011.5$yony
<br />.tflic.nr for rrtfmirsuhjch rhc nptli.a kr ncivilpcnolrrofnor Nrc ihr! filc hu rtddolh^(s500)
<br />-l-a\orrcroflhcpmtEnt.ormycmtloy.cswilh*dg*Nrh.n{n.ornF.sarbn,willdolh.w.*mdrtrsrmtunmrinrc.dnr or o0.rcd for ele (Ss.7(}14, 0usirc$ rnd Pmlcssions Codc Thc ( o.rachrs Li.cnsc tis dcs no! ardy ro a, osrcr ol
<br />rhcfmncny who boildsor imtn,E\ rhcR)n. ind who dex skh B.r* hnnsclf.r hcr$clfor rhrough his n hcr o*trcmployc.s.
<br />nrovidcd rh such nnl)roEmnrs rrc mr i, oic{ norlcBl for eL. ll. ho*?v!!. ttE huildi]l3 or impnwm is sld wirhi .m,eir
<br />or()nnlcrirtrtt Own BuiHd sillh.it rhch{r&!otpmvingrhai lEorshcdn n huiu or iryrce rh. ImFny for rh. toin{ of
<br />_1. r! owtrd ol tls !xlp(n!. rm c\.lusn cly .onhrrin! f irh li(n\rd conr' nrkn kr co n'tur rh. lFr i.cr lsc. 7or,r. LrNk\
<br />dtul Ii,Ls\i)nCodc1'hcCotrrrrcroi\l-ic.n\cl.xwdocsrorrpt'yi)!trd*ncroi|x)trrr-shohuil(lsortnpnrc\itu'con.
<br />nM uho .onri.( tur \u.htrojc.h*irhdCr kr.tnrsrli[n\oJ ]{r\urnrbrhc(i rrcttr s t.ircn\c t-iw)
<br />I lnrcxcmo undcr Sc.rio. ,B &PC fdrhisrcr{'n
<br />D e: ()an.r:
<br />_ulatrD&:tr.uurlNs .rQN
<br />!!CLA&UA!
<br />I hcrchr ifl nnrutrdcr ltnilr].1 |ciluryoncorrhc f{)llo$iiCd..lrxii,rN
<br />I hrvcdxi will nri nir r(c'iiti.arcof(i,nsctrrk, Scll:1t!urc rnr {ork.rr ..n,Nnurion. r\ tiovid.d aor htSc.ri({ 17(Xrofrhc
<br />t-rhtr cbdc.,nr rh. pc'fonnrm. ofrhc work nfwhich lhc p.rmir i\ i\\ucd
<br />. . Ca\i\off..\Cr.. €r.{u.rarV<- Cb
<br />".'.,^",*.<r-3(1JD?-61-d [,-,,,..4l-6
<br />\l ""niry,m in,r,. p".r-ratuc orrhc sork tur $tici lntr pcrn r tr is\ucd. I shnll not cmpkry rny pcro. m,.y nrnnct
<br />$ s lo hcmnE subjcd to thc "orlc6 onlrcns,rion ldqs.rc,lirornid. arnl d8N'h ill shruld k+onr nrh]ccr rolhc
<br />!orkcr con{crsali()nnrovisiotrsoiScoiol7(x)ofrhcLrh,codc,Ish0ll.fo hu,ilh .onlPly wilh lMr prcvnionr
<br />WARNINC, Foilurc n, {cu!c sorkcr'conrpcn$li{nr .orcmsc i\ unlauful. ond snlll suhjrcr (.mrl,,ycr ro dinrinal ncnrlri.s rnd
<br />cilil rin.! up tJ oN hundrdd rhousnd dollon (SlL$.000), in rddirion ro rhc cod olcompcnsarion. dr'nr8cs a\ prcvid.d i,tr rh.
<br />Sc.ri,,n.l,)-6,,.h.lih C.',l..rh.Ft,rtlri1rc'.lcc:,/- :-
<br />".,.9-1j lto n*,,.".,, ao-\ irqs$-\L
<br />r teEN\FD r'(tN rRAdllrR
<br />Dl:cuaauox
<br />I hcrchy rftirfl undcr pcnalry ol !.rjury rhol I anr liencd trndcr pmvtion olCh.lls, (conrmncins sirh Seclion 7(XlO) olDivnion.l
<br />oI lhc Busircs Md Ptufcs'.nsCodc. Md hrlkcns. i\ i'r fill f{r& dl clfu.rB,,"""."^,.*, <asf63
<br />(- ( 4 *"**.E7.cx(o\.! 6r.6h( u4ion.T-,,\r'r-
<br />CONIIAIJCIIONIENDIN!{iENS!
<br />I hcrcty lifirmundcr pcnoltyol!.d!ry thot lhqc h o consrruclion lcndiry o8cncy for rh. lcrformnncc ofthe worl tor whkh rhis Fmh is
<br />tsucd (Scc -109?, Civ C.).
<br />AITLICINLDE.CIJ&T.IION
<br />l[nhyall]r und$ p.trrlry or|{rjury otrc olrhc li,lbwni! dcclahrors:
<br />Dcnn,lnmn Pcirnns Adri.\N.rin.d'or Fcdckl Rcgulart \Ilirlc.l0. Pm6r
<br />-Rcqutcd
<br />t.cttcroINoliic ior
<br />-l
<br />c.rriiyrhlr rhc ldcral rcsullrions rceadinE ashc$s rcmorll orc .or npplicrbl. k, rhn priccr
<br />rl!)r. trr.trrtrrul fr)p.d\ l,r trAtr.rrn, I[
<br />]\J,Dlnml o.]\r.nl Si!ntrrtrr.&-^rodi
<br />*,"k/3-,6
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathi ng
<br />Shear Wall
<br />Framing zA
<br />lnsulation/Energy 6 - tr{&\.W)!)
<br />Drywall U IJ
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil
<br />FINAL ''l-fu-lr N,\,u\d
<br />Certif icate of Occupa t2 v/
<br />Notes R emarks, Etc.
<br />IxMcr.\dJ'.s
<br />Set Backs
<br />Erection Pads
<br />Pool Fence
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