|
BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.OWNER BUII-DER DELC I'ATII)N
<br />I hc.chy aflnm unilcr Fnalry of pcrjury thot I {n cxcnut fmnr lhc Conlmctor' l-iccnsc l-lw fo! thc Lllosing rcawnlse 70:11.5
<br />Bu\i.css nl Protcsn,n Codc): Aiy Cir, or Counry shich rcqutc. r Frmil k' conslrucl. drcr i'nprorc, dcnblish r rltt iny
<br />nrucole. lritr ro irs hsuanc. als rcqlnesrhc applicrnr lbr suchtcmirlo lilc a signcd sr!rcm!' rhar heor\h. n h.cn{d ,'d^uMr
<br />ro lhc pmvisions orrhc Conhcro. s Liccnscd tiw (ch,fl.r 9. Co'nincn.nr8 qi(h Sc.rion 7000 of Divkn,n I ol lhc Businc$ rnd
<br />Ptufcsion\CGlc)orrhalheorrhcncrc Drrlarclmmandrhcb!\Glorthcalh8cdeicmpri{,n Anyliohrio.orSc.rhn70115brany
<br />anrlictrnt forn pcmn subjccc rhc rmliclnr ron.ivil!.n.lry.rm' nDrcrh.tr lilc hunrlrcd dolhrs(Sstu).
<br />L r\ o*rurolrhc lroFnr- or my cn,pl,De\ Niri rr8c\ a\ rhcir n,h.o'nnen\dion. *illdo rhl wo* drh.{turucisrkn
<br />inlcrtL{ orofliRln sh (S( 7l-r,Ll. Busnrl\ md ftolts\n,N Cod. Thd Cofurttr's Li..n!c tiw ddcs tror rpfly b rn own . ol
<br />rfu ptrrtdy wln) btrlld( or in{'rolcs tltBnr. d slbdoc\{rImrkhnnsclforh.$cllorlhrcu8hhisorhcrowncnrtk,ycr\.
<br />Irovidcd rh!r {r.h i'nptuvcDtnrsrt rkn inrcndcdoroflird for $h lll h.trN.r. rhcl il.lin!orin{ro\cnrDr t$kl Nirhi',otrc ttr
<br />o{ conptrion. rh. Owncr Buiklcr *ill hrrc rhL hurdcn of Frving lh:[ h. or \h. Jid mr hild or impmrc lnc pmFly for rlt purpoe of
<br />-1.
<br />$owncr ofrhc p^rpcny. nnr crclusivcly conlr&lii8 wirh liccn*d cutrfu.rofi ro consrrud thc pnjcct (Scc 7044. Brsirlls\
<br />aM Pmf.$bn Codr: Thc (i)nrrnckx s l,iccn\c Llw docs trol lnnly ro $n osncr ofpn,Dcny wh{, huild! or i'np$vcr rh.rcon,
<br />ond who conracts lor ch trotccr qith r Conrr.ckr(, li$n{d Nrsuifl tu rhc Conk0crols l,'ccns kw).
<br />I rncrdnrfl undcr smrion_. B &PC fffrhtrcrvn'
<br />Drle: ()vn.r:
<br />u!.)Bf,IixltauPiNl roa
<br />DECLANd.IIO!
<br />I hcrrby sflirmun&r pcnclryoipcrjuryonc ollhe nnhwin8 de.'laralionsl
<br />-l
<br />havc a,rlwill mintlir rCcnificrtcolCo.snr Io ScliI,NUElor *orkcr'.omncnslrion. !s nmvidcd ior hySElion:17(n.trnr
<br />tihor Cdq for rhc pcrfonnrn.c ofrhc work for shi.h rhc p.nnir h ssu.d.
<br />rh. \or[ f(tr shi.hrhi\ rmr i\ i\\u.d Nly*o'kcn dnnn truri,n, nNurrnrccario r' tn'c!nunrhrrarc:
<br />M,clwcst caq rNS
<br />c\a \
<br />-lenirylhlr
<br />in lhc ,,.rlorroncc ol nE * orl Inr which rhi\ pcmil is issucd.l shall oi cnlPl,)y xny lj.n.n in nny
<br />'ann.rs rsro bc.om subl..r ro rh. sof*ns.o,htxtrs n,n Lesofcrlifdnii. mil nBrcc rhd rfI shuuld b..onE subjd hrh.
<br />sorkcls com!.nn iotrfrclkiotrsoiscctionrT0oolrhcljt$rCodc.lsh.ll.hnhwirhcoDrtlywnhrhoEprolniotr\
<br />\ryARNINC Fdilurc fu sur. workctr mmn ns.rion c.vcn,g. is lnltrwtul, d shrll suhrcd !n cnlloler ro ominal lrDalries d
<br />*1$ur:l+uurui15'
<br />).ux)). in lddiriotr t. rh. corr ol conrpctrsrrion. darogcs r\ pR
<br />I herchy afltn undcr pcnrlrr oi pcrju.r rhar I am lftnEd undcr Ch3tr.r 9lmnnmDci'ig $irh S.crtrnr 7(XX, ol Divi!otr:r
<br />of ln Busim$ md Pofc$ions Codc. lnd my liccnsc is in lull loc sd calccl
<br />e 69nalQ
<br />Y{A1ryq
<br />ca!f,IBlJcllaNl[NulNc-dc
<br />I h.Rby aflirnl nndcr Fnalry or p€rjlry rhd thc* isacondtucri{,n kndingrC. y rur rhc psrornun.c ol lhc Bolk tu $hi.h lhh Frnrit is
<br />issrcd (Scc l(D7, Civ. C )
<br />AIILTANLDICLAf,AIIO!
<br />I hort y oliirm undcr pcnilly ofpc,jury onc oflhc followinS dcchranons
<br />DctrElilion Pcfl nils.Ashcsos Norifi .ari.n Fcdcml RcSularidns (Tirl. 40. Pf 6)
<br />R.quir.d ktr$ of Nolifica on
<br />-l
<br />ccniryrharrhc ltdcir l rqula l ion\ rcEtrdi.B 0sbc{os rcnr)v.l rr. norrl,Plic(blc ro lhis pn,jccr
<br />U l,.i ),h:, lhr\.'.'J,hFJFt '. 'nn tr"1{rx rl-r 11. r}n\c 'rL trurr,nF,',nnr lJlnrh..'
<br />odnrn.csJrd Suic tiw\tolnridg k,$uild aro { .ri{nr lrl hcrhyrrnntrizc ir, ond Countyro cnler up.n rhc
<br />L6ld'i=js 201fl
<br />Set Backs
<br />Forms/Steeli Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Roof Sheathinq
<br />Shear Wall
<br />Framino VZ*ztr ^6tlnsulation/Ene rgy
<br />D all
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lvlasonry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Beport
<br />Flood Zone Certif .
<br />FINAL 6/r?/tv 7.l;'6d
<br />Certificate of Occu pancy
<br />Notes Remarks Etc.
<br />COMMENTS
<br />Subf loor/Vent/l nsu lation
<br />Pool Fence
<br />l*nJr'' . AdLLr.'
<br />rhinc 'mnriom{l prol)Cn} for insFcrionpurn \cs
<br />,\pplient or A*ent Sigorlurel
<br />T------
<br />I
<br />I
|