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BUILDING. INSPECTOR RECORD
<br />SITE.WORK ID/SIG.COMMENTS oWNER EUILDI]R Dl]!-CARATDN
<br />I hcrcby rllinn u.dcr lf,Mlry ol p.rjury rhd I an crdq)r lnrn rnc Contu.k'r' Licctrsc Lnw i{tr thc folb*ir8 rcaanr (S(.?0ll 5
<br />Busnr$ and Proicsi.n Codcr Atry Cily or Counry *hic[ rcqurcs r nomir ro otrslrucl. .lln. imprcvc. dcnrli\h or Eprt an,
<br />srrucorc- Ifitrk, ns issuine- oho rcquncs rhc lpplicrtrr ior suchl]cnnirto lilco sisncd sr,renrnr rhrr hcor \h. ii li...\cd pursudnr a
<br />lo lhc prcvkions nrrtr conlraci.r's Liccnscd bw (Ch.flcr 9. connrcn.irg wirh Sccrion 7uD oi Divhiotr 3 ot rhc l,usire$ and
<br />PolessionsCode)orrhor hcorshc i\crcnur thcrcfrotn and lhc hasi\ lor rhclllcsed cremprion nyviolariotrolSccrioiT0ll5btiny
<br />0Dlicanr ror r Fnnir subic.rs Ihc nmli.am to,civill,rnnlryornor nrrc rhnn 6vc hundrcd doll$ ( $Jfii)
<br />I.ds owncr of rh. prcIlcdy. or rycnpk'yssunhsrscstrsrhcirsnc..nfcnsrion.willdorhcworksrkltlr trMh,.1
<br />inlcfrb or oflircrl lor sk (s(.?()4-1. Busitrcs rnd Pbr.siotrs C.dc Thc Conrdols l,iccns tiw docs nor appl, i{, d.owftr or
<br />rhenmFny *h hxilds or improlcs rhcE)i, snd who d{rs ch*)rkhinNclrorh${lforlhou8hhnorherowncnq,n,y.c\.
<br />B)viJcd rhar su.h irpovomn* m mr i ctrdcd.rorcGl lor slc.ll ho$cw IIE hriUiu or irymrcm n skl *ilhi',om )sdr
<br />ofcon{klion.lnc Owncr Buildc!,iIna$ lhcbu ctrol'prclint tlut hcorshcdil ml buildorinDnrc llE pmrEny tu rhc puryrxc or
<br />l. is o*trcr.frlrc fm|[rrv. anrcx.luriu.lt cotrtlcring {nh ln.trscd.oihr.r.i{ r,.otr{nr.r rlr IJr.).c! (Scc.7(!1. Inrrnc$
<br />and t\nri$hn Codc: 'l he Conrrlclor\ L,iccn\c l.!* doc( frr rrply ro an osncr ollrrorcrry *ho hril{k o' in,F,v.\ rh.rcoi.
<br />d who coirnd\ fr \kh pmjccrs qnh I C.nrmckn( n liccn{d nurs'rnr hrhcConr cktr s l-iccnscI-.w).
<br />I rmrr.n,pr undcr SNr
<br />]vlt8trEts:l;0Mt[Nta.uQN
<br />DECI,AAAIION
<br />I hcrcby trfln undcr p.iah!.fp.rJuryorE ofrhc f(rlowing d.clardiotr$
<br />I hlE fl1d willntrirtrirrccrrillc.rcofConsc to Sclt.lNurc lnr snrkor $mDcn\oi ion. ar pmided for h, Stlin .17(x) of rhc
<br />Ltrh, Cdl.. forrhu l,crfonu..c.fthc work fd whi.h rh. r.nnn h i\{rcd
<br />_lhalcrnd eilimrinr.nr rorkcF compcn\r'ion iNumrcc..s rcquncdbrSdi,)n37lx)olrhcl-a6.rCodc.rorrhrpcrrornbnceor
<br />rrT rr(.\c
<br />nnir i\ i$usl Mywo*cs .om|tnsltion nNunncc.nicr lnnr)licy Nnrhcr uc:
<br />Co..\\\16\ {n(w{ r,rv. r"-r.- (D
<br /><>-'Tln1D?-61-6(a - 6t-\q
<br />-\J (cnify th,r itr rhc rcrlmrnrnce olthc ror[ lnr whnh lht Fflnil n issucd. I \ltall nor cnpk]y dy pcnon in any mr.mr
<br />v, ,r t, b..om sxbi.r b lh. {orkdt srDcnsdbn lass oicaliromid. and a8rc rh,r irl should h..onE subrd ro ihc
<br />workc*'.\,nlpcnsdionFovirions.lS..rionlTfi)or$cbtFrC.xlc,Ishrll.fonhwnh.o.rplywifilhostmvhions
<br />WARNINC Foilurc lo wurc rorkcrl conwcnetion .ovcnSc is unlowrul. and \iJll surrrccr on c ulort ro rinrinil Fmkt( and
<br />civil fines utt lo oR hundrcd thouslnd doll0r (S100.1ru). in addirion nr rhc con ol comFnsaii.n. dntrugci rr provid. tat rhc
<br />?_ tx and dhm) s icc\ ,. ^\
<br />apprimtr,: Jc-eY [{tr\lL\t
<br />I I(',FNSF r| (',()NTRA(lToR
<br />,"'", t.-l
<br />DECI,Af,6.I]ON
<br />Iheby.lttm undd lcnalr, orp.lury rhd l0 li..ns.d undcr pmvhiotr ol Chryrd 9 lconmErcins *irh Secl ion 7lX$) of Divtion .l
<br />or rhc Busi.cs md Pofcssior$ Codc. and hrliccn\. i\ in foll fdcc aJd.fli.r.,T2
<br />L,(ctr.c(hs u Ltrr \cNu,hr. <2<7 tt1(3-\
<br />CONSIAUCIIOAI,ENDINCIIiENCI
<br />I hcrcby dnrn utulcr tEnnlry ol,,.rjury thd rhm is...nsru.rion lcMins r8cncy lor lhe pcrlormmcc ofric *orr for ahkh rhis,xnnir is
<br />i*u.d (Scc :1097. Civ. C ).
<br />AELrcANLDSCIAIAfl9!
<br />I trrbt lllmn undcr pcn.[y of p.rjury onc otrhc lollowinr dNloralions:
<br />Do k,lhi(,n P.ifrirs A\hcnos Norin alion Fcd.ral Rccularions (TirL {{,. Pan6)
<br />Rcquir.d btrft .1 Norili.ri.n
<br />_l(cniiyrh rhc tncrilrc8uluri r! rsfdinr nshe(o\ rcn0vrl lrc mr imli. lJlc k) rhi\ pn,j.rt
<br />IccniftrhdIhNcru rhiirppliurii mJ idcrhar rlr rhrc intuflnrri()n i\.orNt I Fdro.onr,rysihillCiryindCotrnry
<br />.rdi,hic.snnd Srirc lro\ rcldingro huihling.oiirucri,nr. m hrrchyuhtrizcrctrc*fltnliv.soirhhCnyi.dConnryro.n(crup.n(hr
<br />rtx,k Nn!on.,ltnn.ny nr i',\nccrii,n l[rto\c\
<br />/lpDli$tr| or AAetrl SiaMlure
<br />\\$o+R N\t\klj- ttr
<br />Set Backs
<br />Fo rm s/Stee l/H o ldown s
<br />Erection Pads
<br />UFER Ground
<br />Subf loor/Vent/lnsu lation
<br />R oof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />D rywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlasonry
<br />Pool Fence
<br />Handic ap Req.
<br />Depuly Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />A
<br />FINAL 1-zo-t(Y.v-+rll
<br />Certif icate of Occupancy \J
<br />Notes Remarks , Etc.
<br />DATE
<br />SLAB Floor
<br />T-Bar
<br />I
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