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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNDR AUILDER DELCAiATION
<br />I hcrcbt rrfinn undcr F.alry or Frjury rhnr I m cxcmfl trom ltu Conk{cnns t,iccn{ l.r* lnr lh. blkrwi',s rcMn (sec 7(rl 5
<br />llunNss nrn Piofc\sion Codc): Any C[t or Counry lhich rcqunc\ a Frnir k, .o nfld. ahd. nnpro!.. dctrrlnl .r rorn any
<br />$tucrtrrc- pi{n lo ilr i\urcc. nlso rcqunc\ rhc npplic r lu such llnnir ro lil. . si8.cd ndcNtrr lhd tr o$nrc is liccn\cd nururnr
<br />to rhc pNvisio.\ ofrhc Conri.rofs Lic.nscd Lrw (Chllrd 9. Conrmcn.i'rg sirh sc.rion Ttxx) or Division I oT rhc Blsinc$ rnd
<br />,"on\\i{,nr Code) or rh.l tE or shc hcrcnpr Ihcrcfr.niftl lhc hr\i\ tur th. dllc8cJcrcnlrio. Any vnlldiMoiSccrion 7l)ll 5 tyany
<br />rrpli.dd lari p.rn)n suhjccr rhc 4pli.rnr b acivilpcnalry.lnoi nFrcrho r'ivc hundlcJ dolbF ls5dl)
<br />I.!\owrcrofrhcpn,JEny-ornryetrDbyecs(irhwaSc$ast,rn c.onlus.ltrnr. wrlldo th( work ud lhc{mluE i\ nn
<br />i c,xldl orollar.d Lr srlc (SN 7(!4. Busincs rnd lt{'tcsions Codcr'l hc Cofrft.ttr s l,iccn\c Liw docs norJl)ply t, m oqioof
<br />rhcpmli.ny who huilds or in{'o6 rlEren..ri lhr lllrs $ch wod( hnnsclfor hcnclf.r rhior8h hh.r hcr own cmoloycc\.
<br />Frvidcd rhlr {kh nnnft)rnrms (. rkn i,ncrxlcd $ ofiircd i(n {1. lll hosc\ cr, ihc h din8 or i'nnnMmnr i\ sold *irhi" otrc ylr
<br />ofco $hri(,n.rltOwncrlluitl.rwillhavrrh.huftlcnol'pDvirarlnlhcor\hcd norhuiklori'.proKrhrpmpcny,'{)rrh.pdqr){ol
<br />l. rsos.cr.l rhcr.p.ny. nDcx.lr\i\cl!coftn.ri'rg qrh li.ci\.d cr r.r.rtr\h$nnrurrh. tro]t.rISc. 7r!-1. h'!Ns
<br />n'kl lh,la\\i,nCoJc ThcConrr c(n s l.i.cn\c I r$ d{e\ DorrfDlyn, .qm, ol frt)prny{ho 6uild\ o' i'npnrrs rh.roon.
<br />rtrd sho .u td(s nn su.h pnrJ..h wfh i C'u rNttr( \) li(i*J lfu^urm k, rhc Coikr.ktr-s Li(ci\c Ltrs ).
<br />I trrc\c rtn urlc'Sr.r
<br />Drt€ Ornerl
<br />wotxi:nii:inrpnrsrxrr.r
<br />DEIIAMIIAN
<br />I hcrchy afifln u ndcr petrrlty ol pntury orc ol rhc follow irg dNlrdi.ns
<br />-l
<br />hilc ond will nEn oir0CcnillcorcofConscdbscll.lnsuBr(aworkc6-c.nll,cnsarior.!s ptuvidcd r'o!bySslion 37lDol ihc
<br />kbd Cdc. nr de p.if.nEncc ol lhc work f(, whkh thc Jl.mn i\ i\ru. .
<br />rl'c(orlntr$hichrhnjf,rn,iri\n\urJlvlr*okrs.conrnctr\rr,'triNtrrrncc.rtrirr klnolicvnutrlb.rrc
<br />-l.cnily
<br />lhlr ir lhc pcrli,mlncc oirhc work hr shich rhn |cflnir is isucd. I shrll nor cnrrl.y in, Fisor in any numr
<br />{) ns b bcqk \!b]cd ro rh. sorkc^ .onwtrslrn,n l3N\ otCrlilornir. md lgrc. rhrr irl \hould bcconr sohF.i b rhc
<br />workrr $mpcnvrion lrovi\ions ofsccrt'n:l7r[)olrhc Lrhor (odc.lihrll. f{]nh*irh comply Nirh rho{ pnrisnnr
<br />lvARNNc F9lurc f
<br />::":lJtl
<br />*curc qo*cr compcnsariotr.o\oae. is unl.*ful. rnd shu \ubid an cmtloycr h dminal pcfllrics and
<br />Mmd rhousand dolla^ ($10{1,(Xn). ir addir nio(h...n oa.omFns.rion, datMgcs !s proridrd lor thc
<br />P-".":;
<br />I l[E[yrnnnrufticr |[trrlryol Dc,jur!ihrl I Fiovision ol chli,rs 9(conDtrncnr8 wirh Se.liotr 7olx)) oll)ivi\ion.]
<br />!'1 rhc8trnnc(a Pdis\idN Cod., Md ry li.dtr{ i\ i'r fullnn( frl.llcrr
<br />s:-LienseN
<br />It slttl1(ltj)N]t;!!2ltliiclirrI
<br />AITUI.:ANLIIDI:LTB^IIO!
<br />I hcnty oltifln undq nctrihy oft'crjuryotrc.lrhc lnllowir8 dcchr.lnrns:
<br />LXnn,lirion PcrnrirlAsb.sos Norili.!tion FcdcrrlRcgul.rtr'n\ (Tirl.40. Pf6)
<br />-Rcquircd
<br />Lcrlcr., Nolilicrliotr
<br />l.cnLfyrlI rh fcdcralr.Srllrnnr\ tottml, ! r\hc(ovcnxtrrlrrc nrr{,t)l'rahtu n) rhi\!nrc.r
<br />-l
<br />ccniiylhd lhnvc rcnd rhh0pplicaln,n elnarc rh l \c irhnmrrior is.onccr I rareb.r'
<br />.n1,nrn.r\ rrl srrrc I$s rclxr ,$ h huildiDs cotrnrucr rtrrh.,D. i.nrc\.nrrri\r\ ol rhis
<br />rh)!c mnr i,trul lmpcny htr irt,ccrionl
<br />nDrlir l or
<br />^xrnl
<br />Sixtr lur.
<br />+5"*u/::izilk
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Sublloor/Vent/l nsulation
<br />R oof Sheathing
<br />Shear Wall
<br />Framing I lhl^i.w ,ar/Y?i
<br />lnsulation/Eneroy U
<br />Drywall plt,"l tt Tu 1\\u(--ac ,h)
<br />Ext./lnt. Lath U I
<br />Brown Coal
<br />It4asonry
<br />Pool Fence
<br />T-Bar l-'Zo-/e r*t4??D
<br />Handica p Req.
<br />De puty Final Report
<br />Engineer Final Report
<br />FINAL vl/ ///1114 xw{d-t .D/
<br />Certificate ot Occu pancy T U I t----'
<br />Notes, Remarks, Etc.
<br />UFER Ground
<br />Flood Zone Cefti{.
<br />-"**"{
<br />I h(cl,y all-rlr lolcr pcndryofpcljrryrhd lncrc isacon(ruclion lcndiryrsch-yn rh. IL f.ruic. orrh. w. ft* shich rhk l'$nrir h
<br />issuen (Scc.1097. Civ C.).
<br />Lctrdci( Nr r
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