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BUILDING- INSPECTOR RECORD
<br />SITE-WORK ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVl nsulation
<br />Roof Sheathinq i il.u l,t*d/y\rfi*-/ to-.-
<br />Shear Wall ,I
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />l\,4asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL NAk fr llbzttklrv
<br />Certilicate of Occupancy 't I -
<br />Notes, Remarks, Etc.
<br />OWNER BUILDER DDLCARATX)N
<br />I hcrcby rlfirn nnderycnrh, of perjury rhli I an eiemlr from rhc Conh.lds, Lic.ns L{w fot rhc ioll]win! rcasn ls..70rl 5
<br />Busincs arxl Protcs\ion Cod.): Any Cny .r Cornry whi.h ruquircs r Fmit lo onslruct. alrcr inll,rovc. dcnrlis[ or EI,on nny
<br />$rudurc. prbr ro nr nsuuc., als requncs lhc alpliconr ior such pci'nir h filc s signcd n,r.mr rhd lE or she is liccnrd pursulnr
<br />b rhc F.vnionr ofrtF Conh.t,\ l-ianscd hs (Ch,/cr 9. Comrrcrcnrs $ilh Scrlion 700t, of DivGion I ol lhc Busin.s ind
<br />Pmlcsions Codc)orrh.r l[orshc kcrcnfl thcrclromrnd lhc hash lorrhclllcscdc&'npridr Anyviol,rionolSccli{,n70ll5hyany
<br />npfli.,d lorj p.rmn subjNls lhc opplic$l rorciyilr.n!hyolnol docrhan 6!t huodrcd dollds($5ur)
<br />I.* DEncr .f Ihc pn'tEdr, or ary cm oFrs*irh w!8cs$Ihcir $lc.onlrrssri,)n. silldo rh. so* ril rh,trru is mr
<br />i .nlcd or ofcrcd lor sk ( Ss 7(X4. Bu\inc$ Md hoti$i,nN C{ . ]'hc Conhkror s Lienrc tjr does nor lPply fu !n own$ or
<br />rhcpmNny {ln, builds or iqmv.s rhd6n. rl who dms \u.h sn* hnnsclf or hcncll or lhn,trgh hn or hf own cnphyccs,
<br />pi{,vnhd rhd such in,onrlcnrnrs tu mr i,nc*i{ or ortRl lar qL. ll, howcvc.. ihc tnritliu or inDrotnt is skl snhii onc }tr
<br />ofconrphri.n- rh. Owner Buit+r*illhave rhe ho'dcn olpro nglEn hcorshcdid tror buildori'ntrn,w th. fNpdy lorrlE ptrqxxcor
<br />I.r!opncrofthcUoFny.aDcxclusivclyconrraclinswnhliccnscdcontrch6k'cotrn..rh.pr+c'ISN.7014.Bu\i.us
<br />!frI lh,rl*\in, Codc ThcConh.nn s Licc qcLrwdocsndrtrtpitr.niowncrofprorcny$hohuildsorimpnM\rhcrcotr.
<br />nnd sho conlmch lor such proFrs wirh ! c.nhdo(n liccnscd pnnumr brhcG,ntnckr'\ Licc.sc tiw)
<br />I rmcrcn,nr undd S(rn'
<br />tlaaf,D&ucoutlltaJraN
<br />DF(:LARATIoN
<br />I hcrcliy.lfirnrunds lrnrlryol ncrjuryoncof rhc ainlowingdc.h$ridt\:
<br />-l
<br />hrvc arrl eillmri rin r Ccnificrrc ol C.Nrii t, S.lr lnsurd lar *orkc^' d pctrsdi.n. n( providcd ii* bysNrnrn r7molrh.
<br />c. l Ihc DcrrornnNc ol lhc eort ibr{hi.hrhr nsnir n n{'.d
<br />tr s.rkcn .o frn(rn.D ln s lcquircd hy Scciion.lTfi) ofrhc hhor Codc.lor rhc pcrl'onutre.l
<br />n insur rc !:dcn pli.ynunrh.tarc
<br />c/'lDt -ot
<br />I c.nily lint ir rhc pclfonBncc ollhc !ork lbr sIich lht p.rmir '\ i*trcd. I shdll tr.r.flrJ'hy r.y Pcron in nnJ nrnrr
<br />s) rs b bcoE ruhicd t, rh. so'l.r\ .oDfrnsdii lnss l Crlili,irir. xAru. tld il I \h.uld hlt.'tu nrbtd ro rlt
<br />workcrs .onlr.sdrbnpR,vni.n(.fSc.lionl7L$.frhcLn r C.dc.l\hrll. i,nhqithco Dly wirh rhot lnvnion!
<br />1l/lRNlNc lJhtrc r, \..nr. \o'lo^ .otr,tf, \rri(trr .fr..xsr r{ u tu|. rtrrl shxll \uhlc.r rn cn,nl,Dlr t,.n riNl Nmhi:r
<br />.iril fin.\ up b onc hutrJr.d rhou\rtrJ dollnr\ ($l(X).0U1). nr lddir ri,tri. Jx rg(\ r! lr^rtil 11tr rlr
<br />I h.rrhl r,ltD, trn,lcr I[nrlr!of|f,rjrtry rltrr lxD I flcr9t.o n,rncn,g\[hSc(ri(!]Trxx)rol l)ni!i,n,.l
<br />.f rhc lnNincs!and ProfrsnnN Codc. ry li.ctr\. it n lullfrtre. cllt.l
<br />ljAN f,IJCUANIINDINC]II NcI
<br />I hcrcby 3flnr uftlcr Fnrhyofp$jury rhnr rh.rc t r.otr$flcrir lcndrnE lgcncy ilr rhc pcrfonlrmc olrh. woik for trhich rhi\ P(nnir t
<br />tsEd (Scc..lrr7. Civ. (:.)
<br />ATSLICANLIECLABAIIQ!
<br />I hctEl,y s,Inn undcr pcnlhy olpclioryonc oaihc rolbwin8 dc.ldariotrs:
<br />Dcrtr,lilion Pcrmirs.Asb.st.s Notificurion fcdcralRcEul!riotrs (-lirlc40, PM6)
<br />R.quircd trltcr ol Notiarcarior
<br />(.niltrl rh. lrnc,rlrcgul&otr\ rc3&lirP
<br />)n i\corNl. l.E e Io comtlyuith allCny,nd Counryrhrr lluvc rcadrhr\ trp|licrri(nr irxl ':--":"uanl*
<br />DATE
<br />Brown Coat
<br />waffr
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