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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />SubllooriVenVl nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq
<br />I nsulation/Energy
<br />D rywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />u-lv.rJ,,aFINALloIAG,E,)
<br />Certif icate of Occupancy 0 \ (,r'I
<br />Notes , Remarks, Etc.
<br />OWNER BUILI}I'[ DELCARAIION
<br />I hcEhy amrnr undcr rEnalty of pcrjuly rhlr I en crenrpr lioD rhc Conrrrk,' l-i.cnrc Lrw roi rhc rbllowins rco$n (Saloll5
<br />ausirc$ ,nd Ptufcsn Cnlc) A.y Ciry or Cbutrty uhich rcqxir.s a Fynrir to consrrucr. rlrcr. improvc. d.nbliah or tolJn ,ny
<br />srru.luE. prio o its issu.ncc, aho rcquncs rh. .lplic.nl fo. such pcrmil ro nh ! sistd srarcftm rhdtuor shc k liccn*d pu^uunl
<br />h rhc lDlisions ot dc Conra.roas Li.cnsd L2w {Chnpr$ 9. Conmu.ine silh Scclion ?000 of Division 3 of rh. susinc* .nd
<br />Pnrlc*ions G)du) or lhr h. or rh. $ cxcnDr lhcEfon d'l lhc hsis lor dc albscd cxcnrption. Anyviolarion.fSc.ii T0ll.5hylny
<br />applicrnrior r pcrinil subJaG Ihc !!plicanr ro acivilpcnalryolnot morcrisn liv. hundrcddolla^ (550ol.
<br />I. as owmr or rhc ,rcFny. or m, cflrdoyes wi'h waScs !s th.t blc coDrcnsrion. *ill do rh. work dd rh. i*1uc i\ mt
<br />inrc cd oroficEal lor el€ (Sa.1C!r,r, B!\im$and Pmlcsion\ Cnlc Thc Conta.roas Li.cnsc kw docs nor ll)nly ro sn owncr of
<br />lhr pmfcd, wtxr buiktcor improvcs rlf,Rnr and elr, dos \u.h sod( hinsclt or hcrsc ll or lhrcleh ht or h.r own c t,rloy.cs.
<br />rnvi.lcd rhlr ru.h impmvcmnts @ mt inrendcd n orlcEn lbr sh ll no*e!.r. lh. tiliklin! or in{,ovcmnr is $ld wilhil onc tctr
<br />of conplctiqr. rhc owrcr Buiklcr virl hos ltr hudcn of povirB rhll lE or shc did .Fr tuih or irymvc rhc poFny ror rrt pxqb* or
<br />-1.
<br />asoqner oirhc tmpcny. amcxclusilclyconrradins wirh liccnrd conl,acth o.o.docl rlt,,oj.tl (Scc 7014. Bu\inc\\
<br />and Pn,r6\ioo G,Jc, Th. Contacktr \ Li..ns.I-aw d.rs nor +tly t, !n owncr olproFny sho 6uild! or imrrovc\ rht.con.
<br />lnd who.onrnKtslorsuchIrl)jcdswirhaconlmcro(rliccnrdpurulnrbrhcconk,.t,\Lkcnsctjw).
<br />-lrucx.nrfl
<br />undcr Sc.l B &PC lnrrhis rc.rrr
<br />]raBtrD&r-(lJllu,Nl roNI)E!L!IAIIo!
<br />I lrrdh\ rll 'D utrdcr En.tLriol r)d[].yfn. flrh. n)l[$n,c J..lrrr otr\
<br />_I halc Md {ill tuinrain r Ccnilrarc of C{)n*nr t! Sclf l n{rc fd sorkcri conr,.nsar i('n, !s fmvidcd ir by S..rio :17mof rhc
<br />Llhor Cdq ri'r lhe pcrfomncc of lhe sork for which rhc Frmil h hsu.rl
<br />I hak r J sillmai'nrii *orkcrJ ..iqcn\ari({ insurn.c., r\ rcquncd blS..ri 3700.l Ihc Lib]r(intc.lar rh.lanornhmcof
<br />rtu aorktur shih rhis pnnir is irsut\l. M!workcr-co rfisrri(,n irsuntr.c ciricr rnl plicynu'.hcr tre'
<br />-lccnify
<br />rh0r in lhc pcrturroncc oalhc sork tu $hich rhis F.rnir h hsucd. I \hall mr cmploy tny p.Mn in rny ronncr
<br />$n\t,brcorsubj.crrolhcworkcs'.onrtcnsurionlrwsorcahrornir,rndl8ernarilrshouldbcorustrbjccrt'rh.
<br />work.* .o 1pciq n'n pmvhions of Sati :l?O0ofrh. tjhor Codc.l st.ll. ion hwir h conrply sirh rlDs pn,vi\io.\.
<br />WARNINC: I'rilurc ro ccurc wor[cs c.r,pcnsur cor.'rge is utrhstu!. rDJ \hrll srbi..r r c [hJ.r n) (ririf,'l Fmlrns rn(l
<br />cnil nm\ up to onc hundrcJ Ihotsand Jo1h6 I )0.(x1r)). in rd irion t, rhc cos of.otrrtrtr.rrrcn. i.nn8cs r\ F)ridcd li,r rhc
<br />Sccrion .l()76 olrhr lrlhtr Codc. inrc(
<br />n"",Q9 24- l 8
<br />!lLllnl]!!o!
<br />I hrrch! affinn unds r(Mlr! ofNrlury undft fovisiotr ofCnrptcr 9 (comnENin8 wirh Serion 7un) orD,vision l
<br />ol rhc lltr\i'r\\rrd l'n,fcsi(trN (ink. rRl ,y li.cn\. n i', h,11tu'c( ulltcr
<br />14t99iD
<br />.^,",01-24-18 R, '.{;l rOl G<nevc,-L(r"1g1rr
<br />I hcrcbysflirmu c! Irnaht of p€rjury lhrr lhere h a onrlruclion hndinsdsenc, tor thc p(f6rniRc arrhc work ior which lhn lErmir ir
<br />issucd (s... 1097, Civ. C.)
<br />a[tllcaNlDlillltxaurr!
<br />I tf,ylbr 8Ii, n uxlcr pcnallyofI,c juryonc oflhc rollowin3 dcclaftlionx:
<br />D.trrlirionPcnhfs Asb.iosNolificolnrn Fcd.ml RcSulaliotrs(Tirlc40. Pan6)
<br />Rcquncd kucr oi Notiff,,rion
<br />lmguLrn toEldnrg r\hc{os'cnk,!rl rc trornlt)li(iblc t, rhi{tn,jccr
<br />;crdxdrhisq'tlic.tn,nnM(rrcrhitrhcnhovci hnr ion iscorccr lraBro.o'nplywirhrllCirlrtrdCounry
<br />; Irqs-_ldir! b htrildir! cotr{ru.ii.i. dd h.rcDr_Nlhrrizcq)rcs.rlxrnrs ofrhi\ Ciry id((iudyt,ctrrcrnB,nrhc
<br />^,.,O9-21:18
<br />Pool Fence
<br />*rt
<br />trnd.r'i Ad'h...
<br />I
<br />E*f'Is a @
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