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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE IDiSIG.COMMENTS oWNER BUTLDER DI]LCARATION
<br />I hcrcby .lfirD trndfi |). rlly .I rrjury r[d I u cxcm0l rior. thc GnracloN l-iccn\. t.,w rff rhc rolb{ir! rE anr (s..70:ll 5
<br />Busnr$ 0nd Profc$nrn Codc) An, Ciry or C.unly shich rc{nirc\ ! Ilcrnir to con(tu.r, nlrci. nnlrovc. dcirblish.r rqxn !rt.
<br />{rucr!!c. prtn ro ils i\suancc. nlsd ftqunNrhc 0tl,li.r r tur \u.h pciinirro lil. r siErEd ({lcmcnr lhar |.tr or \hc is li.ctr{d Pu*urtrr
<br />lo tl[ provisions nlrhc Cont.n.lor\ Licensd hw ((:h,plcr 9. Conrnrrcnr! *irh scclk,n 7fix) or Divtion .r of rhc Busincs and
<br />P!,lcsion\Codc)orrhurl.!.rshc i\crcnrfl lhdcrrormd rh.tusis ror rhc allcecd cxcnrplion. AnyviohiionofScctonT0ll.5byrtry
<br />rynli.anr r{n a Nrnli( suhjeF rhc ,mlican o . .ivll pcm ht ol not nrrc r han lile hundEd doUrE is50o)
<br />TOAfl'&i:TOMITNI'AIION
<br />Ir[ct aSAuaN
<br />I hcrcbyrffift nndcrp.ialryorl.rjuryonc.lIhcrolk,wn'tdc.lddrio s:
<br />-t
<br />havc !r.l sillmainruin rCcnifi.ar.orCotrsc tu Sclr lisurc ror woikos conlpcns t,n.is pr.vidcd fttrhys.crn,n 1?o0orrhc
<br />bhor Codc. for
<br />'hc
<br />pcriormne of rh. worh forwhEh rhc p..mil n h\rd
<br />Ihnv.rndwillmdinrlinwork$rcomp.nsr ion insunrncc..{ rcquircd hySc.rion.l7ff}ofrh. tjhorCodc.lor th. Pcnnnurcc oI
<br />rh. work ft, whi.h rhil p.nnir ir i$ucd MyBortcrr conrFnsarion in$rurc crrtr rnd poli., nnmb.r dc
<br />Idi.y Nuar$.r
<br />-lipircs
<br />-l
<br />ccnifyrh ir rhc pcrl'orrolce ofrhe wort ftn *hichrhi\ pcrmir i! i1\ucd,, shall not cnDloyanrPcr{,n i'rdnyndnftr
<br />\o is ro hccoft rubjcct b (hc workss ompcNariotr la$s oiCrlilnnir. and Jrrcc rhd irl sh.uld h.tonr subi€l h ltc
<br />wolkLJ\ .u'Vcneriun tmvisions of Scclion 17tx) oI thc tarnr Oic. I shnll hnhtrirh comlly wilh lhos nmrhi.ns.
<br />WARNINC: Fnibrc lo $cue workcr' .onrpc.sdir c.v.ragd is xnlnwtul, trnd shall subicr an .mrlolr b alnm,l ,).ntltks and
<br />civil firs up to one hundled rhon{id ddllaE ($l0o.0oll). in nddili.n ro thc cosr oI com!.nsaln,i. duugc\ rt providcd ntr lhc
<br />Sccrion -10?6ofrhc Latnr Cixlc, inrcrcardnd ariorftt s L.s.
<br />Afirllonl:
<br />uclilsEllcsNlBActgx
<br />ITEII.A8AUA!
<br />I hcrhyrtfirmuM.r,En,h,ofacrjuryrhar I n lienln undcr rovhion ot Chrprcr 9 (ofrmrrrg wirh scction Tuxl) of Oivnion :l
<br />of rhc Businc*rnd Pmf.rsionl Codc.,rkl nrv lkcns h in rxllfoR. cllicr
<br />Li.cnsc Cln$:-Lic.n\. Numb.rl
<br />C9II,IIBUSII(III.IIIDIN!.f,CEN.CI
<br />I hcrcby rlfirmundcr Fcnrlry olFrjury rhar thcrc n a.onsrru.tion lcndinB agenc, for rhc Frrormanc. ofrhc srk tor *hich rhh Jf,mn h
<br />irsx.d (S.c 1097, Civ. C ).
<br />LcnJcrs Nsmc
<br />-AIILICANLIEIIA&SIA!
<br />I h.r$y rllnn undcr p.tr,lly.l ncrjuryotrc orlhc loln)winE dcclarulnnN:
<br />D.nrliri.n Pf.rir* Ash.{os Norifrdn'n FedcralRCBUlarions (lirlc40. P j6)
<br />R.quircd titci of Nolification
<br />-l
<br />ccnily rh3r rhc tcd.El rcgrhibn\ agardin! r\b.sk,\ rcnbudldc mr aPplicablc b ihis Pojd.i
<br />l.cniryrhd I hrvc rcd this ipplicdion lrt slardhar rhc ltrvc info.lEri.n l.on..r lasmro.onDly snh allCiryiid Coutrry
<br />ordinln.csrndsr.r.h*rclalinstobuildinscotrnrudion.nnnercbycuil.iritur.F..c.rarivcsoathisCilynndCounr,kcnr.ruB,nrht
<br />rh,vc mnri rd pmpen, for insFcrion pury.scs
<br />ApDlicnnt or A,rol Sknnh'n
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />lvlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL 7ln)tq -flr22)
<br />ICertificate of Occupancy
<br />Notes, Remarks, Etc
<br />-1.
<br />!s owrc! of rhc pmtEdy. or my cnrploya\ sirh vasc\ as rhci, slc rodprtr*lnrn, sill do lhe pnk and lirc slran@ ir mr
<br />inrcndcd oi ofrcrcd tor salc (S*.7(}1.,1, BusiNss and Pn,rcsions Gd.: Thc Conlradois Liccnsc Liw doer nor aptly
<br />'o
<br />ntr oRn.rof
<br />rh. pn,Frlt *ho builds or mp6v.s thmr ud eho dmr $.h w,lk hi'nsclf or hcrcli or rhmlsh his or h.r ow. cmployccs.
<br />proracd rhsr such iqmwmnrs m Nr inrendcd oroltercrl tbrsk li hrsers. rh. huildin8 or i nl,mwmnl is $U silhin onc F
<br />oI oroklhn, lh. Owncr Buili+r sill hovc lhc blrden of p,ovins rlEl ,E or sh. did mr huild or irprow tne I'mFny lor rtE Puqrs or
<br />l. as o$B of rhc I,opdy, m cxclucivcl, .onrra.rinS wirh li..ned .o racro^ ro d,nsrrucr rlE l,roi*r (s.. 704.4. au\ircs
<br />lnd PDEssbn Co{c Th€ Contaclfi's Liccnsc Ij* docs nor rpply r. ,n o*nf or rrop.riy who builds or impmvcs rhcreon.
<br />nnd sh..onrddshrsuchprojchwithaOontru.rois)li.cn{dtununrrorhcConrturoriLiccnsljs).
<br />_l rd.xcnl)l uM.r scction ,4.&P.C iorrhhElson
<br />Dot.: Ovn..
<br />t4trJ.. .
<br />^'l,t'c\
<br />I
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