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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNEX BUILDER DELCARA'tION
<br />I hcnhy rfiiin undd IcMlry of pcriury rhar I am cxcmlr r'rom rhc Conrracxns Li.cnsc Lw ror rhc followinE rcNnr (Sa ?0.11 5
<br />BusiDcs rl Pmicsion Codc): Any Ciry or Cot y which rcqute\ r pdnrir t) conslnrc1. allcr. iut(trr. d.molhh .r rr['rn Jiy
<br />srrucrue. prior ro irs i\{uancc,,lso r.qnncsrhc amli.dtrr nx su.h Fi.tril lo lilc u si-sncd nslcnEnl rh,r h.or shc k liccn*d Puruanl
<br />b rlr l,ovknrns ofrhc Conrrcttr\ I-i..nscd h* (Chsir.r 9. Com,rcminA wih Sc.rion'7OO{).I DivkiDn 3 oi rhc Ausirrs and
<br />Pnntsions Codc) or rhtrr hcorshc n cxeqrr rhcrcfrom and rh.l,lsis forrh.alkecdcrumflion Any liolllbnotsccrion?0]l 5 by rDy
<br />lprlicanr lor a pernn subjcck rhc dmli.anr roa.i,rlpcmlry.rnol nNc lhotr livc hundrcddoll,* (5500)
<br />l. N oqn$ or ttu t olcdy. or my cnrplo)er wilh wases us rh.ir v,lc r.'nPctrl,ri r. willdo th.wotk drhcnturLftkk
<br />irr. lsl oroftercdfor\alc(S.r7044.BusincsrdPolc*6nrC.d.rThcCo ftctoisl-icc!\cli*doc\norapplytortroqrcrof
<br />rhc ,n'ltny who buil& or in{'Frcs rlEron. atrd who dcr such wrt iinscll or hchclt or rlro!3h hn or hcr own cmpn,r{cs.
<br />prcvidd rhri such iipmRnrnh m mr i, cRlld or ofrcNl Lr eL ll Il)*cE rlt hikliDg .r imF,vc rnr is $ld wirhin onc }!T
<br />ol enrrhri,tr. th. Owncr Builhr sillhavc lhc bodcn orprolin8 rlln lf, or shc dil nor buik or iqme rnc pn,Fty ror ltI Pulx)kol
<br />-1.
<br />a\ouncrol rhc F'pcny. aDr.r.hsiv.ly.otrta.ii g wnh li..fscrlconticlo^ lo cotrllrucr rhc pmFI lSc..7044.8u\i cs\
<br />nlll] Prsfcsi,trCodc-lhcCotrnNtofsl-ic!trscLrqdocsnorrpplyh!nown.rol|m,rcdywhobuildsorirnDnvcsrhcrcod,
<br />lni *ho conrrrch rbr such pmj.rh $irh a G hcbd\) li.cisd tursumr lorhc(inrr0ctu s t.iccnsc l-nw)
<br />I rm.x.'ntr u .r S..ri,)1{++d' "-
<br />DICLASAIION
<br />I hcr.byalfirmtrndc!pctulr,.f l).rjury.trcnfrh.lolloqirt'lLrl rlions:
<br />I hak drxtwill nDintliraCcnifici'cofConsnrlo Sclilns!rcn, *orler'co'nFjtrs,rion. !s providcd for bySN'ion]7m orrh.
<br />lihtr Codc. rff ih. pcrrormn.c of
<br />'h.
<br />wolt lor which lhe psnit is Gsucd.
<br />--lhrvcrtrd will nrni u sq[en conpcnsrii,m in\u.amc. rs rqritdbySccli(n:lTlr0oilh.L ror(i,Jc-ntrhcJ[ airnrmcof
<br />rhc $.rl |'l)r shich rhtpcnlir i\ is$td. Myworkc^ .o |.trsrrhr tr(ur.rcccailicr anl0oli.ynu'n6.rrc
<br />P,)licy Nln$cr-tirf ircs:
<br />l.cnlfylhrlifthctrdi)nMnccolrhc{orkli)rwhichlh\pcrn,ir ni*u.d.Is lltroi cnrPloy!n} |xr.n inrn, rmmr
<br />v, nsro hccom suhjccr r. ihc $(trk.6 onDctr\ (i{n law(.l cnlinntri.. d ryrccrhar iiI\hould hc(rt subirr lollE
<br />worlcn.onrpcrsi{n,pmvisionsofSc.rioi:l7t)()ofrhchhrC.dc.lshill-fonh*irh.ondrwirhrho$ln)vitions
<br />WARNIN(;: Fallurc rr ccurc workc conrp.trr i.n covcngc is trnhwful, itrd lhrllsub]-(l arl c.ll]lo)!.lo siainallir'lrics nnd
<br />.lvir i'rs up ro onc hundrcd rhousend dolh6l$Ift.(xxr- in dJnion kr ihc.oi olco.lFasaliqr. dlmr8cs a1luvidcd ft, rhc
<br />Sccriotr 1076 ofrhc trtn Code. inrercd lnd rrrurcy s lcc\
<br />t
<br />I hcRb, lfirm unds r.nrlry ot p.rjury rh.r I rn li.u*J utrdd Plnvili{,n ol Chrprcr 9 (co nrrN,n8 trnh SNrhn 7U)0) of Dili\ioi l
<br />ol rhc Busi.c$lnd l,nrcsionr Cod.,,nl nry lic.n* i\ ir tullnr.c rftlclttcr
<br />Liccnsc Cltrs:-
<br />QNEIBIJCI]ANIENDINGAAIIII
<br />I hcrchy lifirmlndcr pciahyor!.rjury th,t rhcrc is rconsru.rion hMiry a8cmy rorrhc p.rrortu,rc olltu {or( tor $hichrhi\ pcmir i\
<br />hsu.d (Sc. 109?. Civ C.).
<br />Formsi Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Rool Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsu Iation/E ne rgy
<br />Drywall
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil
<br />FINAL lold|ft to ,z.t-g ,)
<br />Certificate of Occu anc
<br />Notes, Remarks, Etc.
<br />Set Backs
<br />Sublloor/VenVl nsulation
<br />Ext./lnt. Lath
<br />Cuh,
<br />hMclrAddrNs
<br />ATU$NLDECI.ABAITON
<br />I holtf ofiinD undcr l.nalry of pcrjury .nc or rhc rolloNinA dclaral ions:
<br />Dc'nolilion Pcirnik-AstEslos Nolific0rio! Fcdcnl Regolrrion\ 1Tnl. 4'(). P,n6)
<br />Rcquncd t.lier ol Norifi catk n
<br />-l
<br />ccnifyrhar rhc t dfial Egnldions n8ardirg asbcsos rcnnvd ure nor rprli.,hh ro ihk pmFt.
<br />I ccrtify thir I h.vc rcld Ihh aD!licarion dd srarE rhar th. abvc inlonurion is cotrccl. I sEre lo conlly wirh all cilyand Co!nll
<br />ordrdKc\and Sr c L!trr rcl,rins ro hurl{n8.on$drhnn,.nd h.rchy sllhorizc rcprcscnlarivcr orrhh ciry ond c'ounty to cnrer qron rhcffi,-:.:il:'Jx\p_ ,",",lels
<br />Prmile nrn. (prtnl ): -
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