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BUILDING. INSPECTOR RECORD
<br />SITE.WORK ID/SIG.COMMENTS Ol4NER BUII,DER DELCARATION
<br />I hcroby afird trndcr ,.mlry of pcrjury rhd I dn cxcnu frorn rhc G,nrrockm Liccn\c Lu* for rhc rdlowi.! m$n (Sd r0rl s
<br />Ausincs ..d Prorassiotr Codc): Any Cily or Counry which rcquires a lcmir h con{ncr, alrd. nnrtuv.. .tnslish r qEn any
<br />srrucrurc. !.ior lo n\ issuancc. aho rcqon.srhd aiplicMr f(x suchFrnJr tu filc r si8md slltomnr Ihal hcor shc A li.cnrd nu^uanr
<br />ro rhc [ovnions ol'lhc Conrructn\ l-i.cnscd liw (Ch!!rcr 9. C.m rncing wnh sc.rion 7txj0 of Divhi.n 3 oflhc Busincss lnd
<br />Pnnc$ion\Codc)orrhr! h.or\h. *c$nrr rhcr.fr.n u.d rhc hsis for rhcrllcecdcxcmflion. AnlvidrlionofSccri,nT0.ll5bydiy
<br />aprri.rnr rom p.i,nir sublc.hrhc amlica.r lo acivillcMlrtolno' nmrclhon nlc hundrcddollds (St00)
<br />-1.
<br />$ ownerofrhc rotcny. or nrycrpkDes wirn srscs !s rhrt vnc ri,mrtrsdion. willdo ltE wo.k and rhc slmr,rc is ftn
<br />inrcndcd oroftcrednnsh(Sr7(}4]l.AusincssandProli$ion\CodcrThcConn.ctr'sl,icc.\ctiq{tocs.rdmlrro.nnwnool
<br />rhcnmpcny vho tnrilds or inqrmrcs ih.N,n. arxl wh' d,*ssu.h H,rk hinsclf or hcrrll or lhFUEh hi\ or hcr own cnobyccs.
<br />provid.d ihnr su.h imroEmnt N ml irtcndcd or olttlrd lhr sk lt ho*clcr rlE t{ildiig dr in revcnEnr is $kl wilhin oN rn
<br />ofcorohtion- rlEOwncr Auikls *illhlvc rhc hurdc, oi trlins rh,r hc or \h. did nDr build or in{,ovc dc pn'Fny lor ltE puqns of
<br />I. N usm. oI rh. ,tr,ptn y, r'ncr.lusi\cly.oftrdir8 siih liccnscd contridon lo sn,srrucr rhc pr.l.Lr lS(.70il-,1. Sunmrs
<br />md Pdi:sinr codc The C.nrr rcrn r l,iccn\c l-0* doc\ nor apply ti trn .* nf or pn,rcn y who huilds or inrl1rov$ rhcrcon,
<br />ud who.ontacattrsochfmFc(NirhaCoftr.b(nli.cfscdlu6uMrrorhcConlracror'sLiccn\el,aw)
<br />I xm.\.D,j, unn.r S..ri,n,
<br />Daie: OPn(worxrgs c()nrPENs,rrrcN
<br />I'ECLAEAIIIIN
<br />, h.rcby rmnnund& l.nJr, or!.rjury onc ofrhc lolhsins dccltriliors:
<br />I hilt and siilroinrrinaC:cnilicatcol CoNcfl roSclilnsurc lor workcfi (onp.nsrri(,n, a\ ttrr,vidcdforbyScctnnrlT{Doithc
<br />Ijhor C.dc. ror rh. l.rrornrn.corlhc sork for which Ihc pcnnir t hsucd.
<br />lhrvcand $illmrinr0in sorleri compcon(ion insurlncc. tr\ rcquircd h, sc.rt,n l7u)of rhc tjb.r Code.l'or rhc pcrnnromc of
<br />rh. workr.rqhtrhr\sf.rm
<br />'s
<br />isELl V) tr orlch (.n|clelinn in.d' Jr\c r n.' rnl fi,l( t num&r trc
<br />,.,",",.- 9+.ra t C.^f^.r,.al:"^ hgula,,ce F- n)
<br />"""r^*,*,, - 1r i? /d 4
<br />-l
<br />ccnily lhir ir rh. pcrlbrmncc ofrh. *ork for whi.h rhir pcrnrn i! is\kd. I shrll nor.nrd{)y lny p.r$n in any nunNr
<br />$ rs r. tf,u,ft ruhj..r b rhc Eorlcn .ompcnsdln,n h*r ofCllili,mir. ud lEmc rh ifl \h.uld t .onf, {rbF_ o thc
<br />w.&ch c.nD.nsarbnrtuvisionsolScclt,n 17(rool Ihc Lrt r andc.l \h!11 i)nhqirh..n,rlywnhrhosprovniotrs
<br />WARNIN(;: Frilurc k, *cut workd^ uxnFn\ n,n .dvrigc is urlrsful, ,nd shall subtccl an cnDloyc. k, ainiirl drlri.s nnd
<br />ciril ftrs uD to onc hundrcd tho!\an{l dol )). nr rddirtr)n r, rh. r.n ofcon{.nsliotr. damscs N providcd rot rh.
<br />.-t 2 *'q
<br />-
<br />g
<br />Sc.rhr.1076.1rhc lrlrtr (ixtc. .rcnrn ]ra4zetY ,xr r,
<br />DI;(t.,\R,\tI()\
<br />I hcrcby ofiirn undcr rEMltyoipcrjuryrhrr I d lian$d undcr pn'ri\n,n ofCrJl,d 9 (conrnEncins wirh Sccrion 7fi)0) orDivi{ion 3
<br />or rh. Busircssrtrd PmrcssiorsCndc. ari my liccnsc n in lullf.trcc!trdcl1Ni
<br />t4
<br />o"" 99
<br />(c231t-L
<br />l], /,- rE t---2e,;4a^r Z2
<br />CANSIAI TQtr.LEIDIITG.dCEN(I
<br />I hcrcbt aflinn undcr lEnolly.a rqjlry rlur rhcrc i\ a co.dflcri,n L.ldirg d8cn.y fd lhc PcrionlEnce oirhc work r(n shi.h this lEnni k
<br />hsu.d (S.c.3097, Civ. C.)
<br />lxtltc NLDIrcI/aallo!
<br />I lrrhydlinnr dU pctrdlty of trrltrryotrc otrhc lollowinEdcclanlion\:
<br />lXnnrlirnnr Pcrnrir\ Ash(nos No!ll.dloD l;cdcrd Rc8trhri(in\ (Tirlc 40. Prn(,
<br />Rcqrncd brrcr of Norifmriotr
<br />I (cnilyrhd rlrc lc,lcrrlrcrul nn,\rgrhtr8r!h.r.\,rDt)vrlrrciornfflicrbl.blhispr!c.r
<br />icarionnxl srrtclhd rhc attlvc nrlonrurio0 iscotu.r lismr..onlrl!wilhrllCirynndCou0ry
<br />huildiryconstflclion.0ndhcrchyaurhori.crcnrc\.nrdivcsorrhi\ciry dCoutrryloentcrunonricY"b.t^ 'w- q_?r,$l;ltztLt
<br />,..rrr 'nr ,t,. -"4,n^r./,trJtr'J/u.J',l S'xrr h*\ rrlJ gln
<br />Jh[cnrnll,fu.lnmncn}l"rmt*r|/
<br />t\opticant o.
<br />^Eent
<br />silnly-
<br />Pemile n.n€ lprin0:
<br />Forms/Sleeli Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lvlasonry
<br />Pool Fence
<br />T-Bar @,/rs TltE-,n9 Y
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil
<br />FINAL
<br />Certif icate of Occu anc
<br />Notes, Remarks, Etc lt
<br />DATE
<br />Set Backs
<br />UFER Ground
<br />l\\0\\9 rure
<br />tt
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