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BUILDING- INSPECTOR RECORD <br />IDiSIG.COMMENTSSITE.WORK DATE <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loorivenVl nsulation <br />Roof Sheathin <br />Shear Wall <br />Frami <br />wallD <br />Ext./lnt. Lath <br />Brown Coat <br />l\,4asonr <br />T-Bar <br />Handic R <br />De Final Reut rt <br />En ineer Final Re rt <br />Flood Zone Certif . <br />FINAL <br />Certif icate ol Occu nc <br />Notes Remarks Etc. <br />r)rrNr-:R Ir]!t.DIaR DUL(',1R,\lr()N <br />l hcrehy artr unlcr pcmlry of rc.juty lhar l am excnpl ri.m rhc Conrr$r'6 Liccnsc La{ tur rhc lollo*irrg r"hn rqa Tlrl l 5 <br />8lsinoss an,l ltotsnrn Codc): Any Ciry or Cotnty which rcqutcs I Frnii ro on\l 'r. {rrcr' inrPro!' d'nnlkh r rcndn rnv <br />srucrurc.lIk'rt,irsksuancc.nl$rcqutcslhclPrlicnft,srchIErnilofilc!siSncdshrcmnrrhdh'otrhcnliccna\lPunuonr <br />lolhc|mvisiomolllsco.kncl.rsLi.ci\.dljwlchlPlc'g.conlmcncnlEwilhscclnlnTfl]oolDivi\ion]otlhcBu\illc$l.d <br />potcssions Codcr oi rhJth. o. shc ir.xcmDr rhcrctrod iit rh. hasis ftn ihc allcgcd cxcnrtriotr Anyvi{,hrionofSccrionT0ll.5$vinv <br />omliclnr td a rcrmil suhjsh rhc llllicsnr ru,civilpen0lryoahor trxtrcrhan livc hundrcddollaN (55uJ)' <br />I. !s osNrorrhc tmlEny. ot myc'n,bye1wirh wr8c( as rhcir n,lc compcn\s!idn. willdo rhc woA di lhc {murc t ft <br />irrrc.a"a moncrca rm.ic lia.?oi4. Busi.cs md Pruicssionr cod. ll* conrdols Licen\c bw d€s i'! lpPlv ro ar ownd ol <br />rh pmpcny who builds or i'rrl)rord rlfmn. ond wlr d*\ su.h qo* hnns.lror hcnclfor rhou8h hh " hcr owncdpbvc's' <br />pn;ided rh,r s.h inlt,orcmnr\ dc nol inlcndcd or ond{ ror sle. lt k'scvs. lbc huilding or inDmkftnr is soh *irhin m ,! <br />;rc.mpl,jriotr. rhc O*;r Briu.r willhlw Ih. hud.n of!.ovins rhDr hcorshc did n t{ild or inDt'vc lhc pmFnv tor tnc PUIIrY or <br />1..\oBncroflhcpn,Pcny.ancx.lurvcly.onlrrclinswirhli.cn\cd.ont,croftb'onfirclrhcomi'r(Scc'70&r'Bx\i"c( <br />atrd tt,r$sih cod.: ih; co ri.rorsLiccnscLawd..snoroPPlvronnowncrorProl.nv*hobuildsori pntrtrlicrcon' <br />ud sho conrrack for such Dmjck wnl a Conta.lo(r ) li.c.sd lurlusnr o rhc Conlractn\ Li'cns tiw) <br />I nnrcxctr,fl u"dcr Scdion-. B &P( lnrrli{rcrson <br />Dole , ()sner <br />rvonxrns' ctlniPn,rs,rtlotl <br />DECLABAIION <br />I hc.ctyafln ruidcrrcnllryorp.rjuryoNofrhcroll.RmEdccla,arions: <br />lltlvclldwillmi.rlin!ccnific,lcofconsnlt,scl(.lnsurclin$olkds.comFnsaliol.lspolidcdlolhysslionlT(x}oflh. <br />ljtrtr Codc, for lhc perrorffcc of I hc work for whth rh. Pcnnn i! nsucd <br />-l <br />h!!c and willroi rirr*orkctr.ory)cnsarn,ninsuamc..srcl]undhvSccrionl?0oolthc|ihorG'dc-ltrrhcP'rfonBncc'f <br />rhc work td which rht Frn,ir is issucd My{ork.s conl,cnerion insurana cadicr.Rl tslic, nlnhct {c: <br />Cari.r = <br />-__- <br />-l <br />cen ilr rhrr h rhc l}crt)lr,n.c .i thc *ork ftn $hn'h rhi\ l{nnir i\ nsucd. ! \hrllnorcr'plov ryl{6'nin tynanrcr <br />I&rst tciom ur,1..ih lrc *orhcs comFtrsrlion [ws orcnlitornir. ]nd 4rcc ttur if I sbuld b'toN \rl+'r k) rh' <br />\kfkcrs.oDrp.i.ii({f.ovi\ion\orsc.ri.n:17(DotrltlrlrnCfllc-l\halllnnh*irhon\nvsilhrho$!n'vi\ion\ <br />Wi!RNIN(i i lurc r,, *nr. wotkcr'comp.Dsdor c.vcrulc is unls\ful. atrd shill strhjL'r rrl c$Dlovcr ro di iml Pcfulr.l I <br />cieil nmr up lo onc hundrtd I <br />::"::w41u" <br />I hcrchy olfirftxndn pcnrlrY ol <br />h.u\xntl,lollx^ iS (xr.txr ot comp..stin. dfl'Meps as Pnlided for the <br />I <br />9 (connmncing w h Sdion 7ffxl) .l Divhion :l <br />I <br />DTCI.\RATIoN <br />.\du.dcrIn)!i\i, olChxP( <br />g ct6 <br />*"1s!41t0 <br />I hctoIy.rtflnundcr rr rkyoipcrjry d1 <br />i$u.J (Scc. ltD7. Civ ( ) <br />acotr{tu.rdr lcndingrlctr.y lor Ihc |r{'ln nrNc olrhc s.rk li]rshrh <br />su[ri,nN'.Sr(luP trh!(ovrtrtr*]l r'. trf r <br />K <br />.ontly wiih oll Cirt rtrd Counl).))r'{4t;;| <br />Set Backs <br />lnsu lation/Enerqy <br />Pool Fence <br />5f\{tY\l41//ir <br />ol rhc Au\ircsrlid ProlcsiorN Co,lc. Md trry licctr{ i\ id tulllilNr l.llL.r <br />tt "r'" tt'rrr' r' ffi TL? di <br />{r.e+ujtf <br />APPLICANT I'TTCLATIATI(tN <br />I hcrl),aninnu s pcoxhy orPcrjury otu orrhc Llloui.B rlihnri'ns: <br />Dctrnliri(,n Pcirnir!Astinos Nolifi.ilion Ijcdcrrl RceulrlionslTirlc (]. Prn6) <br />-ltc+ir.dLxcrofNorifi. <br />6n