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BUILDING.. INSPECTOR RECORD
<br />SITE-WORK DATE COMMENTS OWNFJR BUII-DER DELCARATrcN
<br />I h.rchy ofilfln und.r p.Mlry of rcrJury rhd I fl.x.'rp! fflrn h. Confuio* l-icnr uw for Ihc follosing rcason (Se?0.115
<br />Businc$ and Pmfcsion Conc): Any Ciry or Coudy shi.h rquncs a pcnnn ro .onsrdcl, 3lrcr. im[ovc. d.nrlkh or rcn0n my
<br />idcrlrc. dorlo ils t\unce, aho Equtcs rhc lpnlic l lor sucn rErmil io filc! si8ncd slurcnEnr rhot hcor shc h licensed pursuanl
<br />Io lhc prcvnions ol d. Cotua.rols Li.c,rsd taw (Ch.ptcr 9. Com.ncin! wirh Sc.!io. ?0O0 ol Division I oflh. Busincls d
<br />Pmfcsions Codc ) or lhar lrorshc hcxcrlpl rhcrcfrom and rhcblsis for rhc alLscd cxenDtion. Any violilionofSslionT0ll5 6] atry
<br />rtplicanrrdrr.rmirsrhjehrh.,ptlica r.!.ivilpenalryolnorntrcthunfilchundrL{doll{\1:1500)
<br />ffi* "**,"i,n"p-p"n1.nrmycmnl.y.cs* h*Jscrrsrhcrs.kcomlcns ion.rvilrdorhe wo*odrh.(n 1Eisnor
<br />\nrn l.,i or ufrcrE l nr \rlc (S.\ 70.l]1. Bu.inc$ anJ Pn,fc\sions C.xlc:Ih. Cooracrtr s l-k.n\c La* doc{ nor "pplr ro {n own*of
<br />rhc rmpcdy Nho buikl\ or iarlmvs rhctuon. ud Nho d€s \uch $or* himsclfor hc.sclfor rhmugh hh or hcr o*ncmplorccs,
<br />pn,vidcd rhar such i Dmlcmnts m n.r irlc cd orotlcrcd n, s.lc. Il howcEr. rhc buildiry or nn mlcm h sold *nnin onc )eu
<br />of coq)htiotr, rlE Ownd Build$ will harr thc bxrd.n .f pbving rhnr h or +r did *, buiu or inpbk rh. ln p.iy fi, lhc ,urp.s ol
<br />l. .r o*R. ol rhc pN|cny. am crlmnrly conr(rire wirh licc \cd .onr,croN n, .unnru.r rh. pmjcd (scc 7()'1,l. Busir'c$
<br />md ftr,fssbi C.dc l'hcConractois!,iccnlcl,awdocsnotaDplylornowncrofpro|rnrelDhuild\orinrprolcsrhcrcon.
<br />0nd who coff r.r s for such nml.cls wirh a Cofido(9 l'.cn\cd l)Usurnr ro rhc Cotrt..tor's Liccns Law)
<br />I rnr.x.nr!r uodcr Sc.ho.='22-tY
<br />"""",Y*s-<+=r'.'q- A\-\-\s'tvoRKFIsr( ( ruPFNs/\T(rN
<br />DIiCLAAATON
<br />! hcrcby ollirnr undcr li(nilr, of Frjnry oN of lhc fdloqin! d..hblt N:
<br />-lhuvc.
<br />qilltruirti n Cenilicntc ol Consctrr to sclf. hsurc lnr solkcrl omtEnsdnnr. as providcd for Iry Sstion l7([ ol'rhc
<br />Uhr Crodc. Ior th. r.rn)mn.c of th. Ro* lor which thc pcn ir is iskd
<br />lhrr rnd Ri1ltr$i'nrin workcr\'cotrDcn\xrn,n insurrn.c. r\ rcquircl hyScc(ion.l?(r,ofrhc lrhor(i c.f rh.p.rfonm ccof
<br />rhc work turshichrhi\ pcrmii il nsud My workcrr con,p.nsrrion inslran..crRhr rd policynumb.rrc
<br />@4ccnilyrhar lnr[c lra;rMnce.l Ihc *ork lirr *hichrhi\ |{rtr i( nsucd.I \hrlln.r cnDloylnyJErron rn anynrnncr
<br />v' k' lE(mr \rhJ.d h lhcsorkcricon,p.nsrrion lawr oi Clli&nrir. n r8rcc rhrr ill \hould l.rom sul'j€r k,rtr
<br />*orkc'\'dnnpcn$rionpii)vi\ion\otSc.iion.l?(x)ofrhcl,!har(ixlc.l\h!ll.liihwirhco'nply*irirtx,{pniri\ion\
<br />$]\RN|N(; Frilurc t, {.!r workdi co rtL srrk,n corctu$ i! utrhrlil. and shrll \uh}.r r c pk,yrr h rnnindl jf, dlli.\ ntrd
<br />ciril ln,.s ut i) onc hrn(lrcd rhou\lnd.tollar\ (S101).{ll)O). ir odnili,,n ro rhc con of co'nncnurion. dnnr4cs as tn)vidcd lnr rhc
<br />Sn'.. ' l0_..,1,h.1ihr CnJ.. inr.,ci:rlrh,r)'s f"9.--)
<br />n,-,, 5' 2)-\V n*,-*,, )(.(oose1* tAJ->)C,
<br />LICFN\T1T('(IN tR{C I ('R
<br />DICTJBAI]ON
<br />I hcrby.ltirnr undcr rnrllyofpcrjury thd I rm lic.nsl undcr pf,'visionofChnplB 9(.onnmncirs wilh Salion 7Ul0) ofDili\ion:l
<br />of rh Busincslnd Pbfdsi.nsCodc. nd,nyli.ri\c i! i[ lull hruc o]xl cl.f..r.
<br />Liccnse Ch$:-
<br />AITIICANLITII:IISTIIO!
<br />I irrby aUm, ond.r pcnrhy ol pcrjrry otrc olthc n,lk,wing dc.larariotrs:
<br />l)emnii.nPcn!ils AshcsrosNoriricarion ltncral kcBul{rion\(1irlc.l0. Pfi6)
<br />R.qoncd lrrrcr,, Noii,i.diu,
<br />-l.cniiyrhd
<br />rrr rdlchl rcgu lario.s rcgtydin8 rsbcn.s rcn$rrl rrc mr nmlic$lefu rhh Fojccl
<br />&Atcniar rhd I lbvc rcld rhi\ arplic{i{,n lnd darcrhar rlrc atrvc nnnrnEhotr a cotrccr IagrNroco'rpl,wirhrllc y,M(outrr,
<br />orriDancc\ d Slnrc h*\ rchiing lo l,t ildirc connrud ion. dhcrchyaulhoriz.reFc\cnririrc\orrhnCny,ndCounrybcnrduF,nrhc
<br />fii( 'N iomd nn,n nt r,r in"pcrDlnur$
<br />,rppti.*r o.,T g"nrsis*ru*,Xt6!-QQY\OC"s- NSaE)
<br />n"-r**.",r",,,X*<\ro\'\cr,\o-. .\\r\^-\)D.,. .s- a&-LX
<br />Set Backs
<br />Formsi Steel/Holdowns
<br />Erectron Pads
<br />SLAB Floor
<br />Rool Sheathinq
<br />Shear Wall
<br />Fr amrng 6/t /l< ,., k,t:.r-rt$
<br />lnsulation/Energy
<br />Drywall l/,il|r sr\gk
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certil
<br />FINAL t/t / lz 5b6y
<br />Certificate ot Occu pancy
<br />Notes, Remarks, Elc
<br />--l}
<br />ID/SIG.
<br />ll)!$IAlcltONlJiNOlN(;iQllCr
<br />I hcrchy rfltmund.r ncnilry oipcrjurr rhlr rhcrc is a con!ru.linr hndirs rscrcy lor lhc n.nomrmc olrhc Nork tr whi.h rhi\ tf,rnrii is
<br />i\\ucd lScc.1097. Civ C )
<br />I. trJ. ''. \rrr
<br />lrndcis Ad&c\\:
<br />UFER Ground
<br />Subf loor/Vent/l nsulalion
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