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BUILDING- INSPECTOR RECORD <br />SITE-WORK DATE ID/SIG.COMMENTS OWNER AUII-DI]R DELCARATION <br />I hcrcby ififln utulcr Nnally oi lcrjury rhd I0ncxcnpt rrorn rhc Cotrtr.l.F Li.ctrs l-r$ lbr thc nnk,wir8 rcrv,n lscc7{).ll5 <br />Bunn.\\ rnd Pn,fc\\ion C{xlc) An} Ciry or Counry shich rcquirc\ r p.nnir lo mnnrud. rlr.r. i'np(rc. dcm)lnh or q'dr in! <br />nnrtuc. uiorro irs issur..., llso rcquncs rhc dftli.r ror s!(h Fnnirb nlc r\i8trcd ndr. Enr rhar h,.rshc ir liccnscd ptrrlur <br />n, rhc n(ti\nn6 of rhc O,nrrr.nn \ l,iccn{d La* (ChJprcr 9. CornnEmi',g qirh S..rnnr 7(X)O .f Divni :l o, rhc llusincs\ atrd <br />Pnnassi( \ Codr) .r rh r h. or \hc is crcnpr rhcrdriom r rh. h!\t turrh.rtlcgcd.xcn{nn,n Aiyvii,hrnr.lSccrionT0ll.5by.ny <br />itplic0nr for a0.rmr suhjcchrlr rfrlrcrtrrro rcivil|xnilryol ior iorc rlrn livc hundrcd dollan(r500) <br />l.a\ oqRrofrhcpn)Fny.o n!rmPby.csNirh*!B.s!srh.nsohcotr,!.n\"rion.$illdorlf,sorkarldf,n dtrrennur <br />iNcnJ.d orofiarcd l lrlc (SN 7()1,1, Busircss rml Pn,L\tuft C,xle Thc Corkr.tr\ Li.ctrsc L.w d.cs tror dnt'l) roano*mruf <br />rhclr)t*dy who huikkor inDn)vcs rhcro,r. Jrxl who {r\\u.hwod hnn\cllor lrr\cllorrh'oulh hi\ or hcrosncmtbycc\. <br />nrtr idcd rhrr su.h inDro{nrnh rr. mr inrcfrlcd or .rtr\l fo' elc Il h*.$( thc hu Lldn]8 .r inDrovcnEnr h sll *irhi'r oN yca, <br />_l.lsowno nl rhcir)ttny. rm cxclulivcly cotrrrM in8 qirh liccDscd .onrricnrs kr.rr{nEr rhc n(&rr (Scc 7(!,1. Bu\in.\r <br />xl Pmirs$tr Cudc ThcCotrtr.rofst-i.cn\c!-audocrnor3ppl!r.,noqndofFrr). y*h. buildsor nnF)vcr rh.rcotr. <br />rnd who conrrrcls fr suci proj.rrs wirh r O,nr!ado(s) liccn\cd ru^lmr ro, lt Conrracroi s Liccn\c l-aw) <br />I d cxchfl und.rSccrbn <br />]IABtrDB5]1;S!ITIINiAJ&N <br />DICL]LBAIIA! <br />I lrfublrrfiirnundd,f,f lrlrlpdJuryoncolihcr,,llo{i'igdcrltrrrri{nr <br />I havc dld will ,Minrnh , Ccdin.dr. .f (inr*nr tu Sclf ln\urc litr sorkdr- .. !.nsnrioo, rs lovdL'd ntr hySccrionlT0Oolrhc <br />trb.r Codc. forrl[Nlfonn rcofrh. work fdwhi.hrh.I,cnnn i! i\suc <br />_l hrlc rM $illnui (in wo c6 coDF-trurion i.\mn..- rs rcquir.d tySc.ri,nr:17(xJolrhc Lrb{tCodc. f.rrh. ndrronnam. oi <br />rhc *qk lnr qhi.h rhis |Ermil ir h\cd. My wortcrs conlrnsrri,$ irsufln.c.rnicr xnd Fni.y trutr$cr arc <br />Iccnii!rhrr inrlr Fcrra ndn.c.frhcworkfdwhi.hrhilFnnir is is\ucd.I sh.lltror cDdoy lny p.rcn in rtry ma.ncr <br />v, ^ ro h.conf, sri,jccr lo rhc wo,k c!s' .o rrrcnsr r i,r larr ol'Crlili,.nir od agrc r1 r il I rhorld b...trf,\ubr..r ro rht <br />woricn'compcnsalnrnrrerisionsolSecrionlT(iroirhetrtDrCodc,l\lull.ionh$irfilr,nrlywirhrho*rovntun( <br />WARNIN(;: Frihrc t, \c.ur. workc's c.nDctrsdriur.orcralc is unlrwlul. id rhall sub.jc.r an cnr oycr ro crinrinll pcnahics d <br />.,vil finc( utr tr otr. hrndEd rhousrd d.lld( (3lm,O(D), in |lddIi( ro rhc.on ofconrpcns.rn,n. domiEcs ar provi{tcd iq rhc <br />Sccrion 1076oflhc trh, C.dc, i crc(and.norrcy s fccs <br />Drk: Applisnt: <br />t.lcrrvsrn ttrxturrtrn <br />DECI,IB{IIAN <br />I hcrcby aflirn utuld lcnrkyorpcrjury rhal I rn li.ctr*l under tnrrisbn orchrpr$ 9 (.orNncinS with scclion 7r[0) otDivnion 3 <br />ol rhc Busims and Pnlcsrnrns Conc. e, nry liccn* h in tull li,r.c uxl eflirr <br />coIsra.ljcrl()NLENullcilirtill <br />i\lucd isc( 3097-Crv. c ) <br />I-ci(Lcr\ Aildr.\ <br />iIftU$nUiCLrAi\IlQN <br />I tf,tuhy rlttDrufttcr J--nrtry.fJxrjury om or rhc nrtn,$in3 d.ctJrrid <br />l).trDliriu Pcm rAshcsos No'iiicrrin l,cncrrl RcEu ir( F ll ir[,r0, I'rn6r <br />Rcqnicd lrrrcr ol Norill.llion <br />I Nn'li rhr rh. rcdcrxl rcEUhrion\ r!udi'r3 an{no\ rrnn\rlrrc noi $!l'.rhl. t, rIn Ir)rc.r <br />-lccniiyrharl <br />havc rcud rhislptli.rriona,xlnorc rhnrrh.rt$ve iriormrri{m is cotrccr laFehcon,plywirhrllcilyandc-ottrry <br />odirrnccs rtrd Srarc bwr Ehnng to bundinS ..nrdcron. drl hcrcht {urktrizc rcprescnllrnrr,)frhh Cirylnd G,onrt k,.nrcr uBn' rlr <br />ivc nrcnrn L:l Frpcnylnr i'rsfNrion NryJsc\. <br />,\DDlic{ orA*rnlSi*nrlur. <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />SLAB Floor <br />Rool Sheathinq <br />Shear Wall <br />Framin s <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />l\4ason ry <br />Pool Fence <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />Flood Zone Certif <br />fl/t't//d @teDr ,h. <br />Certificate of Occu pancy <br />Notes Remarks, Etc <br />UFER Ground <br />Subf loor/VenVl nsulation <br />T-Bar <br />FINAL