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BUILDING- INSPECTOR RECORD
<br />DATE ID/SIG.COMMENTS OWNER EUII,DER DEI,CARArlON
<br />I hcrehy afirn rndcr ,.nrlry of pcqury rh.r I m.xcmpr lion rhc Conrrlo6 Liccis bw ntr ihd following rsson (Scc.?0:11.5
<br />Busincs .nd Piolc$n,n Codc) Any Ciry or Coutrl, ,hich rcquires r pcnnir t, .onnru.r. ahcr, nnprovc. dcnnnhh or rcplt uy
<br />(ruclurc. p,ior lo ils issuoncc, rlso rcqunci rhl,pplicanr li,rru.h Fnnir t, fiLo sigtrcd {alcmnl rhar heo, shc ix li.c.\cd Nrsudtrr
<br />b rh. lmvhiotrs.r'tr Conkrdols l-iccnsd Liw (Chaplcr 9. Conrmercin! sirh S€.rt,n 7fir) or Dilisiotr ] ollhe Businc$ and
<br />Psfc$ionsCodc)orlh.rh.orshcisercmplrhcrefromlndrhcnshiorlhcrlLgedcxcnDrion.AnyviolntionofSarisT0ll5bttrny
<br />ryIlicrnr for a pcrnir \ul,jcck rhe applicd.r r. acirilp.nslryofnor nxnrh.n fivc hundrcd dolhr I S5m)
<br />_l.asosncrol'rhcpm|rny.{n'nycfk,y.cswirhwngcsr\rh.nsb.otrrtf,trlirnnr.willdorhc*ort,ndrh.( rh1si.r
<br />iirc(lcd orotf.r.d nr srlc (scc 704-1. Busincssand Prolcssions Codd'fhe On rodoi\ Liccn\c tisdocsnorrtplyIortro{ncrol
<br />rhc lopcny who 6oil.k or inrpnNrs rhcKnr sJxl *ln) doc\ \uch m)* hinsclfor h,*clfor lhmu8h hh or hcr o*n cnlnk,tccl.
<br />ntuvitlcd r hdt $ch n\&^eN.h e rn iorcnlGl o' ou!E{ lar eL l I hos?ru. rhc hihirg or i'npnnutnt n ski *irhin onc )cr
<br />otco'Iq)Lridr rh.O*trrr Burlds wrll h{( lh. hurdc..i lrot'ir8 rhar hc or shc dil ftn hrilt or in{nnc rhc PmFny tu rlt ruF)tol
<br />-,.
<br />a\owDcrolihc prcpcdy. rDcx.lu\l\cly.otunctirg qirh liccnscd.o rtr bFbcon{tucrrtu8i..r(SLt 7$ .|l!sinc\,
<br />trnl FlDlis\ionC.dc'lhcConrrrror\Li.ctrs.LrsdocsiorlnplybJtrowhlruftn'pcriyrhonui[kornnpn,v.srhcrc.r.
<br />rnd who.ontd\rdsu.hprojccrssilhd(.ontNrrr\)ldnre'lnunur t, rh. Cunim.ttr\ lrctr* t-r*1
<br />ldcrcrnDrun.lcrSc(uon .B & PC r.rrh''.,rntr
<br />uaatrDlls:g)llflNs raN
<br />DE.CI.AIAUAN
<br />I hcrchr rafilnuM.r pcnalr, ofpctur, onc ofrht r(nk,wi'ig delararnnrs
<br />illnuinrail r Ccnificaic olCon{ t) Scllln\ur. fd sorkcr!' .onu.n\rrion. rr !n)videdfnbyS..ridrl7(xJofrhc
<br />rh. NrfonrEncc olrh. work li)r*hich rhc Frnir i\ i\\udd
<br />ir *0kcr\. rorrt)( \xrnr insutun.c, as mquncdbyScdnnr 1700ofrhc lihorCodc. iorrhc|c lnmutrccoI
<br />s ..nxnsarn,n insuruNc caricr snd Fnicy iu'nhcr ml
<br />-l
<br />cnilirhx( ii rhcF .rnDmcofihc sork ior $hichrhn pcrnrir is hrucd,I \hrll norc P[,yrtrypcNon in rtryuBnncr
<br />$ Nro bcorE rrhl.d lorhc!orl.n comp.n{rnr hw\ ofCrlifu nDd n!r.. rId il l {hnnll6..off, suhi..rr)rln
<br />solt.r conf.n{rlon provision\ ofS.crbn lT0Oolrhd ljhtr ll. n,nh*irhcomply wirh rlr,{ ptovsiotrs
<br />\Y,\RNING: flrlu'r r, \ccuc qorkcri e.nlNnsrri, .o\.rrg.$ cnDk,yer ro snnnirl frMha\ rnd
<br />s!rio!- damAr\ rs pturidcd f.r rhc.ivil fincs up lo onc hundrcd lhouslnd dollas (Sl(4
<br />I h.rcbr.fit utulor !.nrlryoipcrjury Ihol I ! of Ch+rs 9 {.o.mncitrg *irh Setion 7OU)) of Divhion I
<br />ol rh. Busn.srnd lt.lisnn} Co r. d nry lirc \( n $ ltrllln'(iDrl.Tk'.r
<br />C
<br />I hcr.by !ftiinutrdcr flnnhy oINlurylhal
<br />t\ucd (Ss. .1097. Civ. C )
<br />hndingtlacnrrturlhcNni,nnlrccol'rhc$or[iitrshi.hrh(p.nnil i\
<br />A.PIUCAIfDECLAEAII!]N
<br />I lrrcty aJtm r.df pcn,hy oi lf,rjury oflc oithc iolloqirS d.chrolions
<br />Dcmlirion Pcrnrirs Asttdos Norifi.urnnr Fcd.ml Rcgxbrhns (Tirlc.l0. Pan6)
<br />-ltcqutcd
<br />larrcr ol Norirtdi.n
<br />I cc. ili rhd lhc ridcrrl rc-lulalion|rsMliry Nhc{os 'r hhl rc u nu)ri.iblc lo rhi\ rrr}..r
<br />tr iscotrccr I aCre i' dn.pll *irh dllCiry trtrd Couory
<br />rh.rirc rcrlcsenhri!c\ ofrhi. Cir! ad Countyto cnlc, ulion rhc
<br />^,",?/r-'tr
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathing
<br />Shear Wall 4/ttt/tt E/11Un-lc--
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lr/lasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Ceftif .
<br />FINAL qh,*//*Eruazra '/ Dr,-'
<br />Certif icate of Occupancv
<br />Notes, Remarks, Etc
<br />SITE-WORK
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