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BUILDING. INSPECTOR RECORD
<br />ID/SIG.COMMENTSSITE.WOBK DATE
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Roof Shealhin
<br />Shear Wall
<br />Frami
<br />lnsulation/Ener
<br />o/
<br />Ext./lnt. Lath
<br />Brown Coal
<br />It/asonr
<br />Pool Fence
<br />T-Bar
<br />Handic R
<br />De Final Re rtut
<br />En ineer Final Re rt
<br />Flood Zone Cenil
<br />FINAL
<br />Certificate ol Occu anc
<br />Notes Remarks, Etc.
<br />()\vNI,lR lltrll,l)tiR l)l:1,('ARt\l loN
<br />I h.rby aflirnr und.r peolhy of F4uty rh,r I am ucnrll fmm rh. conhcloF' t-hcns Las tur rhc follo*ing Msin lss ?0'll 5
<br />Busincss .d Prcrcssion code): Atry Ciry or Counly shich r.quirc( ! Il.flniio con(tucr' drd. nnrov' ticrmlhh or to!'t atrv
<br />(rucrlr, lritrlo ns nsu..., rlsorcquncsrhd itplidffr nx such p.flnir ro fil.r sign.d stotcnrcnr rhar fuorshc ir li.cns.d purslxir
<br />lo lhc o(Nnn,ns or rhc Conlr&roas Licctrscd Llw (Chaprcr 9. C.mNncins wirh S"rnrn TuxJ ol Division I o' rh' Btr(in's rnd
<br />pior.rsionscodc)orrhlr hcor sh. iscxcnrpr rhcrcti.nr.nd rhc basis for thc lttscd.rcmllion Any viobrionofscdic,n?011.5 bya.t I
<br />q'rlicrtrl for rncmir *ubjccG lhc rfflicrnr lo rcivilncmlryornor flsr.rhrtr fivc hundrctl dollan ($5m)
<br />-1.
<br />ar o*n.r of rhc proFn y, or nry cnlrlorei with s+cs is rhcn v,b comlcn\ nrn. snl do rnc $dkand rtc {mDE k ft'
<br />inhndDd or ollcEl ftr saL (Se.7044. Bu\incs\ {nd Prcfcs\i{J codc] lhcConh..lolsl-iccnr'tjsdocsiorrp,'lvlounowftrol
<br />rhc pmpcdy {lx) }dilds or imln,es dtNn, si wh, do6 such uo.k hi'nrclfor hcMlf 'r rhmugh hn otls own cmllovccs'
<br />pu,,ia"A rt a *.r, impovcntnh d rx, ir crd.i otolTcid ftr slc ltl h,w.rq.ltE huildi'g d in!)$vcm k $11wirhin o c v! tr
<br />lr.onDlclion.lhc o*;i Buiklcr willhrrc thc bunlcnolProvi'r8 rhd tE or shc did mt huild or nl\aott lhc IreFnv for rh' pxrlnE ol
<br />-1.
<br />asown.r orrhc [otcny. nn.x.lurivcly conrracring qirh licen\cd co.tact$ h La,n{nrct rlE Ini (s'c 7Or"' Btr(i'rcs
<br />u d Fbrssfl Codc: Th; C.nlrrcroi s Liccnsc Lotr does nor trlplv to u o*n.r ol |xotcd, *h' huilds or imProvcs rhcrcon'
<br />ond *ho.onh.hfors!.hrojcclsvilhaC.ntmcrons)liccnscdruAur r. rhc conlmcktr s Li"n\c k$)
<br />-l
<br />amcrcm/ undcr Sslion-. B &PC ftrrhisrcason
<br />D.r. O*ner
<br />]IABtrIIN:.CAIIIESAIION
<br />ll&cLABAuo!
<br />I hcrcby affinn undcr pcnaxy oI psiury onc oflhc follo*ins dcb,rions:
<br />-l
<br />halc dnd will rmnrrain o Ccnifictlc of Con(nl ro sclflnsurc lor workcn cooPcns,iion. !s Edvidcd ior hv sNrion :]7fi) or rh
<br />tjhor Code- lor rh.!)crfonMmc orihc work for *hkh rh. !.irni h n cd
<br />-lh,v.and$illmai.rsinwoltcsco'nP.Narioninsuramc..sr.quncdhrsccrionS?ulofrhcliborCodcr('rhclt.rrormNcolih.*orkforwhichlhiipgnrisnscd.MysorkcncomPcns,ri,nnsurlncc..fticra Polic, nunbcr dcl
<br />Crtricr _
<br />-Ertircs
<br />-l
<br />ccniayrhsr inrhc lcrlormtn..ofrhc wotk li,r which rhis Frnrir i\ i\$cd.I \hrlln'rcn{'lov uv l'Mn in rtrndnEr
<br />"*.u, r...," *t'r""ir",r," *. cr'confc.srrion hws olCnlirdnr. r rsrc.rh il'l \houltt bcNm $hjc( lothc
<br />",rk.^ ntrnNnnri,r l,mv,istuns oisccti.n lT(x)ol rhe lrhrr CGlr.I shall hrnhsith comply wirh rhot nrri\ionr
<br />WARNINC, raihrc b scurc sorkcr{
<br />.ivil nn$ !p k, .N hnndtc lhousnnd
<br />Scction .lll76 of rh. titsr Cod.. inl.rc(
<br />,,,,".- 5/r I rB
<br />rion cov.lagc h lnlsstul. and stall \ublc.r a. cn,Plorq ro mninal Fntlri's md
<br />).0()0). in kldiii{rtr ro lhc.on {,l..rnPcnsuli,,n. drmiscs rr ftul edttrrhc
<br />DECLAAAIP!
<br />Ih.Eby0mrmund$r.6tllyof0erjurrthallanlienwlrndc{rmvnionorCh.Prs9(L$fr'mrcirswirhscdhnTUx)r'rDivirion:l
<br />of thc susincssmd Pbf.$nnsCodc, tu ny liccnse is in fullror.c lrd cttc.r
<br />. \h+1 9 70 l(tt 1
<br />o"," - 5/r I tt coDr T1 . --^ ?r?<r'lrl:)
<br />eoNsl lltl("rl()N LENlrIl\(i aG[N( Y
<br />Ih.rcbyafinf,nnddlcnallyorp.rjurylhallhgcislconslruclFnknd'n8a3cn(yljtrlhcn.rfnrm'(.ofttrwnrklor}hichlhnFnnilist .d rs.c 3097. Civ. C ).
<br />tJnJr' . NJn'c
<br />llndeas Addrcss
<br />A.EIUCANIIECIAEAIIA!
<br />I r.rcby rlilmr undcr Fnally of pcrjury onc ol rhc ftnbwiiS d(l.ruriq$
<br />Dc rliriotr Pcrnri( Aqh.sros Norificaii(,n ftdctsl RcEUl,rids (Tirlc '10- Pan6)
<br />ItdLtrn.(l I .rr.r,n N,i li(xrnr
<br />-l
<br />ccnifyrh lhc icd.ral rcEul.lions sg-d$8 rsbc{.s rc'n,rnldrc tror lprli.,blc lo rhis Pdi'r
<br />I.crril-v rhrr I lrvr r.rd rhi\ r0Pl'crri( rnl{rrcrhd rlt rhivc inln'trrrridr s coftet. I 0are lo.onply *ilh allCiry lnd Coxmy
<br />rcprscnhriv.s ofrhi city.nd Coudryro cnrer uF n Ih.
<br />D.'. -<-/ I I l1
<br />ordininccr and Srrrc ljws elllin8 Durlding..n(turrnrr nml hcrchv rdl$ri7c
<br />Set Backs
<br />Subf loor/VenVlnsulation
<br />zGEJ)cg>-?o-tO
<br />>(?v)-//eSoaDrywall
<br />"rQq)i-r*r8 J/eSa{/.
<br />,h,vc nE.horcd prcIl.ny tnt
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