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BUILDING. INSPECTOR RECORD
<br />DATE ID/SIG.OWNEX BU!LDER DELCARATTON
<br />I hcr.by nffinn undcr F-nolry oi pcriury rlur l !D cscnrtr froD rh. Gnrdos Liccnsc L,w for rhc folk,wint rcNnr (sc.70315
<br />Businc$ nnd l\.lcsrion Codc) Aiy Ciry or C.unry which rcqutcs a Frnir ro condocr, rlb. nnrrovc. dcnFlish or rclan ,ny
<br />{tu.rm. prior ro ir\ hsuak-.c. aho rcquncsihc amlicatrr l'or such pcrnrir b lilc r siS cd srdcnEd ihll h..r shc i\ li.ctr{d pur.uanr
<br />ro rhc pmvnions of thc Conkdrtr's Licctrscd tiv (Chi!r$ 9. Coflnncncin8 wirh Sd.rid 7flr of o vision 3 of rhc Brsin.s\ dd
<br />Pturcsn scodc)or(h,r h.ors]f 6crcnfl rhcrcnor d thc br\is tu rh. rlhScd crcmF iotr Anyviolrlionoasctiio ?0rl.5iyatry
<br />rmli.ad lor i pcirnn subj(N thc lpplic,nr b ( civ il ll.mh y or nor nrrrc rhntr irc hundlcd doll$ (S5fi))
<br />I. $ owtur or rhc pn,Fn y. or ny clnDlo)es *irh wiScs as rhcn sh conD€n\tu.n. will do rhc worl dd rhc dtutuc n mr
<br />inrdnbd o.ofcrcd l'or elc (S( 70.14. Br\ine*a.d Eofcsioni Cud.r Thc co rnloisLicc.sctrsdoc\norlPplyroanowocrof
<br />rhe pDpcd, uho hilds or iqrorcs rl'.mn. xt who des such *ol( hiaxclf or hcMlf or rhrcush hh or hcr oun ennk,y.cs.
<br />I,ov idcd rhol such iauoknxnh rc mr i' cndcd or.ficGl ft, eL lf. hd$Ner rhc hoilina ot inl)mEr n$klwi,hinorc}td
<br />ofc.mD!:liotr,lhc O*ner Buildcr willhrw rh. ho.Jen ollroling thr hc or sh. did trol ttrild or imPnrc 6c ntuFry for rhc Purl'osc of
<br />-1.
<br />aso*mroirhc propcny. rmcr(hsiv.ly.otrta.ri,r! snh li.cnscd connicl,n\lo.oii ciIltpr.]ccrlScc.7(I+'r.Bu\in.\'
<br />rnd lh,ftsimCodr: Thc C.trtn.M's l-iccnsc Low doc\ nor opnTy h rn.wicr of pro!.ny who huilds or nnPn,v.{ thcrcotr.
<br />! *ho conrmcrs nn strch pn,i{!s virh a Cuftr.lon r ) ln cnscd l,u6urnr k, rhc Cuntucttr s Li.cn\c tj$ )
<br />-l
<br />ur cicmpr trndcr Sdr
<br />Dale O*ner
<br />w(TRKER.S', ColtltXNS]rTrllN
<br />DECI/AAIION
<br />I hercb, arfirn under p.tulry ol pr.lury orc oflhc folh*irs dccl"nrn'.s:
<br />vc dd *ill mnnain a atn iarc0lc ol Con€nr b Scll lnsurc ror w(rkcs' comPctrsari.n. !s pmlidcJ rd by S(lion 1700 ol rhc
<br />comrcnsarion nrsuraicc. r\ i.qurcdhySsrionl7(Joo,rheLrborCodc,lbrltepcrrortutu.or
<br />n insurancc clricr ud loli., nuntbct arc
<br />D
<br />-l
<br />ccnil, thar in rhc ,'.rloirisncc olrhc sork for lhich rhn lernir is nsucd.I shall nolc;pk,y rny ltcon in any mr.ner
<br />$ ,\ !o bc.onr sub,.rr lolhcsoltcrs comncn\arion hwsofcaLbmin. ! asN lhll if I ct uld b..om subjccr to lhc
<br />workcs' .oDrNnsrrion proririon\ olSrcrnnr :l7fiJof rhc L2txtr Codc. I
<br />!n emPlorcr t, diniral pctrrlrt\ andIVARNINC frailurc t, rcurc work.r{.rn{ci\ari(r.ovcriAc rs u
<br />nsarn,n- datus.l rs lmvidcd r',,r lhc
<br />s(ii,in 1{176rrlh. l lihr(' . i'n.rt.{ rn,l
<br />,,*1:=42-9'/z
<br />I hcrrhyrl1ltrrtr rlcr Nnnlryolt,.rjuryrhrr IrmI q lconnrtRi'rg wirh S..rir 7(Xl)).1l)ni\i{n l
<br />AIIUIAILIIDCI.AAAUQN
<br />I ll,thy aflim rndcr |fMlry of pcrjury om ofthc tollo*ins dcclulrion{
<br />Dcnplilion Pcrmirs AstEdos Noriu.arion Fcdcral Rcgll,rions (Tillc4{, P!n6)
<br />-Rcqutcd
<br />lrrrc.orNotific iun
<br />amltlg r\hc{o\r. nivrl c for
<br />,, n.om.r I r4.c kicoNpLy*irhrllC yrtrdC()ufry
<br />rizr rrr.\mrrhcs olrhi\ Cily nnd Cou yt'
<br />/
<br />'(D/-
<br />*,.,7-20 ,&.
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsu lation
<br />Roof Sheathing 4lot lt&6IWY|l.gfl--
<br />Shear Wall v
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />I\4aso n ry
<br />T-Bar
<br />Handicap Req.
<br />Depuly Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL tol,tllt A N\blw 1s"
<br />Certif icate ol Occupancy
<br />Notes, Remarks, Etc
<br />SITE-WORK COMMENTS
<br />Pool Fence
<br />tl.rhc pc artun cofrh. sork litr shichrhc $nnit is t\u.d
<br />.ivil llnr\ uI tr' oic lrutrdrcd rh.tr\r d dull.6 lSl(Xr.(xX)). in
<br />ot rhc Buri0cssrtrd Phic\sio.s(odL, and myltcn\c is in itllfor.c ril.l[cr
<br />hsued lscc 3097. Civ. C.).
<br />Lcnde, s Nam.
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