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BUILDING- INSPECTOR BECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNTJR BI'II,DER DEI,CARATION
<br />I hcrchy orfirn nndcr pcnalty ()l F jury lhnl I m cx.mpr rr.m rh. Contrbs Lr.nsc ljw rur r hc r(,lb*in8 msn ( s& 70.r 1 5
<br />susi"csr aid Pron$ion Codc): Any Ciry or Connl, qhi.h rcqutcs , Frnnl ti' on$ruct. .lrcr. inltlrov.. dc'nohh or mtEn lny
<br />(ruchrc. priorro irs issurrc.. lho rcqund rh. atplicrnr lbrsuch pcflnir lo tilc! si8ncd nlrcnEtrl ihar lEor shc h licctrs.d pu^urnl
<br />to lhc Pbviqid* or rhc Conrrrct, \ I-iccn*d liw (Chtrnlcr 9. Co,rmcrcir8 wirh Scclion 70(x) ol Divhion 3 ollhc Busnrc$ rnd
<br />Prorisions Codc) or rhrr hcorrhc iscxctrrpl lhcrcfmn and rhcba\i fitr thc dl.gcJ cxcn/ion. An, vn,ldn,nofScclbnT0ll5 by siy
<br />.pplica lor r p.nrir snbjccarhc $tli.anr h acirilpcnallyotmr flBrerhm fivc hundrcddoll.6($50o)
<br />l. rown.roarhcpmpcny.ornrycnDb)rcswirhwrAc\ srhcir $L .onrtrnsir ion, willdo rhc sork tuxt rtr srMruE i\ ror
<br />inrcod.rl oroff.r.dr(rsalc(Sr7Ot4.Bu\incsrndPn,lcsri.n\Co<lcTh.Contrachi\liccnseltrwdocsnorupllyroaoo*ncroi
<br />rhcpmFny $ho builGor inlnn)v6 rtrB)n,ond who das su.h sork hnnscllorh.rslror rhn,ughhisor hcr owncmpl.yc$.
<br />providcd rhd su.h nnrhrcmDkr. nor i cidcd or ofidRl lirr wlc lr: how.vcr. thr hulldi'rA or imprcvcnrd Avn wirhi'r onc ycar
<br />orc.n1plcri,,n. th. Owncr BuiLlcr *ill hrvc rh. huden ol pnNing lltrI lr or nrc d nol huild or inrtmn ihc fmEny hr lhe puqr\c ol
<br />_1. as .{rcr .f rhc pbt dy. ,n cxclusiv.ly .onrrd in3 *irh liccned .onr!.i.6 t' d'nslrucr rbc pr.Fr ( scc 7or4. Buem$
<br />a r ArfssbnCodc: TheContacrors Liccnsc Lowdocs nor rpplyto.noqnm.rllor.dywho htrilds.r inrrotcs thcrstr.
<br />a.d who c.nra.k f.r skhFoickwirhs conhcrr)ds) lten*d purulnt ro lhc conrracloas Liccnse ljw).
<br />I rNcxcnrt, udtlc' Sc.rnn
<br />Dole O*n.rl
<br />woR(n ra\. coMPtiNsAfl oN
<br />IIECI"IXAIIoN
<br />I hcrcby afllrm undd p.mlr) ornciury.k ofrh. r{nbwirs da.-llrariotr\:
<br />-l
<br />hlvc o.dwill nEinl.in rCcnilic0r.ofCo.scnru Sdl{ lhidrc turworkc^ conlllctrnni.n..s tmvnlel f,tr b, Scrion]700 oIrh.
<br />Lrnor Cd.. li} ih. pcrformr..c . f r hd work lar whth ric pcnnir is j\suci
<br />_l havc rnd willmoinr0in sorkcn conFnsrtion nsui,nft. 11 rcquimd btS ri( l7lDolrhc ljtxtrCodr, for rh.l,criornDn.c of
<br />rhc $ork n,uhichlhh pcnnir is Gsucd Myworkss tunp.i{rk)n insurakc.di$ mkl p.li.y.unhd d.:
<br />2-l o -/z-3t-/'
<br />I.cnifyrhrr in rhc,rrfornuncc olihc work rorshichlhis pcnnir is isucd.l $rllnor cnrploy!nyl]cson ir rnynunncr
<br />so m k' h.dntr qrbFd to rhc workcr( conp. erbn lDtr r.f Crlit nir. aid alrcc rhd ill \hould bccom {,bjccr k,rhr
<br />*orkcr\ c.nrpcnsdion povisbn\ ofsccrion lT0oofrhc btxn c{;]c.1shrll. fonhsirh comnly wirh rho{ px,!i\nrn\
<br />WARNINC hilurc h fturc sorkcr'.onrlcns.riotr ovcrr8c i\ utrl.*ful. ind shrll {bjcd on cn{'kDcr h dintu.l pcn(nic\ 0Dd
<br />.rvil fi c\ uI t, otrc hundrcd rk,u\und dollm (SlUr.(xD). iri diriotr ro rhc coi oicomrcnsrb.. d0nr8c\ rs lrovidcd tur rh.
<br />?s-
<br />I hcEbyatlnm trMcr p.nrkyor|xrjry rhd I n li.cn*l untl.r provhi{,n of Chani& 'r (co'nnrcncin! *irh Smrhn TtXr) or Dilili()n .l
<br />ol rh. Bulitu\srtul Ptuf.$ioni Codc, arxl my licn\c n nr tullforcc rxl cftd
<br />a"-* ar*, ' 13 1? z< 98
<br />9-IA .-"""*,)4-B&/l-r*-r
<br />CONSIBI]IIIQXIIIiDIN(iII NTI
<br />I hcrtbt arfim undcr pcntrlrtorFrjuryrtur lhcrc h a con(Dclio! hndiry nacncy ln! rh. performnc. ollhc work nr shich rhn F,lnir ir
<br />is\ucd ISN :l(rr7. Civ C )
<br />A.TTL&ANLDEIIdMIIAN
<br />llE$rafimu.der pcnllty ofpcrjury otrc ofrhc followi.S dc.lahrioni:
<br />Dcmlirion PcrnrnsAsh.sos Norifi.lri.n F.d.ral R.gul.rhns (Iirlc 40. Pd6r
<br />-Requncd
<br />Lcrrcr oi Noriticdion
<br />- l.cnrlyrhJrrtx l.d.'alreulirr,n. rgardmg J\h"n,..
<br />'ctrnvdl
<br />dr nnr smli.rl'l. r, rhn nmJ.. r
<br />[ -n,ry rru t rrorc reaa rrr,. rrnlEahn ud (arc rh0r r h. itDvc inhmrion $ corcd I .8rc to comply wirh lll Ciry ond Cou.ry
<br />6rdmah-,ci snJ skrc lj*s rcl,rinE kr huildins c8n\lrucron. md hcrcbyaulhorizc rc0rcsnrarivcs oflhis City otrd Cou.tylo cnlq upo. rhc(r{dmlll.sn9tl\ A
<br />^,*^i""--^"-*-i,"^"^-"xb:Jl. lTn< n )*,,,. . ?- {-'E
<br />,
<br />"
<br />*u * * ^", o n
<br />^,, *3J\4 fy'ozf 5 oa{e
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />4lnlfi ",&6)
<br />Shear Wall
<br />Framing
<br />lnsulation/Enerqy
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Fleq
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL ftzt 7-Z?-/o
<br />Certiticate of Occu DA nc
<br />Notes Remarks , Etc
<br />+
<br />s\l'.i r,'h^r rhc ljlv C.\lc i' crc{ srd ar. f,}', t'rcs /l ,
<br />'.,",' Z:/z:4 ^ou*,,W71/J,/Kn/LlclNslr) coNln{( roR/
<br />lrl;g.A&$eN
<br />lcrrr \ A,l,l'rr
<br />Roof Sheathinq
<br />Drywall
<br />Flood Zone Certif .
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