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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE IDiSIG.COMMENTS OWNER AUII,DER DELCARATION
<br />I hcrchy ar'ltm undcr pcm[y otFiury lhJl I am cxeflrpt lirrn rhc Conrrlor'Licctr{ lj$ rnr rhr rollosiis rdNn, (ss?o.]1.5
<br />Bu\i'E$ rrl t'rolt*ion Codr) Aiy Ciry or Counrt which rcqunc\ r p.nnir k, conitud. rkd, tuPtuvc. dcmolkh,tr rcFn rtry
<br />nrudum. pri,rt) ir\ is\uaicc. also rcqu,rus rh. rtpli.rtu nn such |tnnirr, filc. si8trLt n.lcnr rhd hcor shc n licc.scd punuinr
<br />h lhc !n,rhn,n! ol rhc ConrEckr'\ l,iccn\.d lj* (Chnptcr 9- Connncnci',9 sirh S.cton 70(n ol Divisn,n I of rht Bu\nt:s rnd
<br />Pi()rc\si('nsG)dcrorrharhcorshcilcxc prrhcrcfn'nnndrhcbr\i\turrhcrllcg.dcxcnrrrioD. nyvi(nntiflolScdionT03l5hy!try
<br />rffli..trr lo. n pcnnil subjdsrhc rppricrtrrto acivilpcmlly.rmrnntrdhnn livc hundrcd nolllrs($500)
<br />I. tr\ own r or tlr p6Fny. or my .mployc.r wirh wagcs a\ rh.n n,b c..rr.nsd io.. will do rhc wolk !d the srtrtE il nol
<br />i dr& or o,Ic,cd tu slc (Se.7014, Businc$ !trd Pmlcsions ao<lc Th. Conr,aclols Licensc l-3w does nor aprly ro M owncr or
<br />rhc !tr,Fcdy who builds or nnptuhs rtEdn. dxl who dcs skh *o!t hinsolfor hf*lror thmlBh his or h.r osn cnqrloycc\,
<br />F)vitlcd rh su.h inlrovcDrms m ft inlcndcrt oroflcral for sh.ll hoqcvcr. rh. burldng or inrE.rcnEnr is sld *irhinnnc rr
<br />ofc.rqihrbn- rh. Orner Bliuq willhrk rlr t.rrco of rreri.g $!r h. or shc did mr bdki or in{mK rh. ptutdy for E I'urrnso,
<br />_1. sowisorrhcptr,Fny-a'n.rclu\ivcly.oitrcrinAsirhli.c\.dconr.h^k,..nslrudrlrp.tcrlScc.?{}14.Bu\ir'r$
<br />drkl ftrrr\si C.dr Th. c(r ru.ktr s Liron\c Lrw docs n.r itJt,iy t, rtr or mr oi Drot.n y * ho hu ith or inprcvcs rhcrcotr,
<br />rnLl *ho conlncl\ for suc[ pn'lcct\ wilh ! CorrBcn](sl li.cn\cd rtrrruur lorhc Cinnrrc(r's l-i.cn\c l2w)
<br />-l
<br />!n.xcnrpl unlc, S.dio
<br />()!re.
<br />]TOB&:&TTA IENIAIION
<br />DIIILABAI]ON
<br />I hcrcbyrrTt undcr pcuhyolpcrjurtnn.ol rhc follo$i'rgdc.lrrrri,in\
<br />Ihrk dNilluinrrinrCcnitlcd.olCotr\cnrhS.lfltr\urcntrqo'k.^ $nlrnsdn{.$ F)vi(lcJlarhyScclion:l7or)'nrh.
<br />Irhrr CoJc.Iorlhcpcrt Ltrcc ofrhc *ork ir $hich rhc pcnnir i\ i\srrJ
<br />-l
<br />h.vc rlrd sillmrinrdin *orkcrs .onD.nlrri.n insuran... r\ rcqunci hySccrion 3?0Oolrhc l,rhorGdr. fd rhc !.nohnincc .l
<br />rh. worl ri,r*hich rhk p.rmir i\ h\u.d lvlywork.n conD.nstrri{in insurrn..ca crrdJx,lky nun$cr ecl
<br />N,.,,., SNuNColMA-lA l- l-\4
<br />I.cniIy thrr iI rhr pcrronmtrc ollhc work lor Rhi.h this !c nil is tsucd- Ishal!nor cnrdoy!nypcron in rn, 'n!tri.r$ s k, hlTom sulrjd Io iirc *o rkc6' co mrcnsal ion lrws ofculilbrnir. u.d agrN lhnl ifl fi,uld h.t t {bjc.l Iorh.
<br />\orkcr( compcncrlion pmvhions olSetiotr 370()ofthc tjbor Code.lshall. forlhailh conrply with rhos F)visnJns
<br />WARNINC: Flilurc ro scurc wortcn compcnsalion covcrlsc is uoh*tu|. rid \hall sobj&r nn dmpk,ycr io snnirll FMhi.s,nd
<br />ro onc hundrt rhousand dollari (SIOJ-Oi)o). in ddirion ro rhe co orconpcnsarion. d,nrlcs rs lrovidcJ lor lhc
<br />Sc.rion 3076ofrl* Irtbr Code inr.rcd,nn ormv rlccs
<br />.,"tlUL l8 20iu
<br />I hcrcbyalllrN uM.r !.tultyofpcrjury rhd I rn li.ctr*n u F)vi!nrolChr cr 9 (comncncir8 wirh Srdir ?(XX)) ui l)trisir I
<br />ol ihc Br\i'r$n Pmfcsifl,\ Corlc. rl|i..tr\c is i! tullturcc mlcllo.r
<br />tcoqq 81
<br />*'"Jtn- n0 2018 Vq!<-rrq
<br />calsltruquoNrlNl)Ml&fflrl
<br />I h.oby rfinn undcr Fnrky.fpcrjury rhal thcrc isa o.$flcr6n kndinS agcncy lbr lhc t.rfofiui.c otrh. w.rk for whrh lhk Pcnnn is
<br />issu.d (S... :1097.Civ. C.)
<br />AIPIICAILDEII.AEAIION
<br />I hr*y nlhn und.r Fnalrt ofrcrjury o.c olrh. aDllowing d..lBrrtnrN
<br />Dcd,lirioi Pcrf,ih Asbcd6! Norification Fcdcrrl Rcgxlarions (Tirl..r0. Pdn6)
<br />Rcqxircd lf,tcr of NoLilicdtirn
<br />Ll.cdilirhd I htrrc rcnd this Jpp h!rritnrnd (xrc rl'nrrl,.rlr]t. L I r8rLr h c.n,iy $ilh allCiryr d Cotr
<br />'ordi'ram.\.trd sfurc b*c mhrine r. buihnrS.onrd.r rhhCirr!!dCornr, b cn'& u,rn' rh.
<br />ntxrc mnrioncd pn|€ny lor inrccrion
<br />Andicnn( or Ascnr Sisnatrrc
<br />(i:.' r rr g
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Ereclion Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulalion
<br />Roof Sheathing
<br />Shear Wall
<br />Framing *lZh/ q sE ttr
<br />lnsu lation/Enerqy
<br />Drywall
<br />Ext./lnt. Lalh
<br />Brown Coat
<br />Ir/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Beq
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL y9\/a 3t)fi'6
<br />Certiflcate of Occu pancy
<br />Notes, Remarks, Etc
<br />c*,. M\dwu \t aAS tN S
<br />r-"",* cr.*, B Lic.n* Nunb.rl
<br />-lccnillrh
<br />rhc tedcal rc8u lul io o\ rclrding a\if,{o\ rcN)vrl trrc ior dptli.dhlc ro rhis prorccl
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