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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE rD/srr OIVNER BUILDER DELCARATION
<br />I hcr.hy alrtm un,tcr pcnnlry ,)I F Jury lh0l I nm c\cDnl Ism lhc CtntrlB l-scnsc Law tu rhc nn[)wiry rcnq,n rse.70.ll.5
<br />arsinc( atui Pn'ltsion Coi.): n, Crry o! O,uly ,hiuh rqNiEs a Frmil r,r .onnruur. ilrcr. imlove. dcd,lish o. rcprn any
<br />{d(urc. lrior rD s isuM.c, al$ rquft\ rhe appliraor tu n'.h lEmir b ilc r rigncJ narcmnt rhrt lf, o. sh. is lic.nscJ pusu r
<br />b rhr ln,vtrons or rL+ Conta.tois l-(cnsc'l liw ((lhlprcr 9, C.nrmcn.inf wirh Sccln,n ?tXD oa Divirion .l ol rhc Burinc$ ann .
<br />Prrlissbns Cdlc) or rhar hcor \hc 6 crcmfr rhcElnrn md rhc bxsn ntrrhc rll.t.d.x.nrptron ny vohrotrolS(li,n 70!15 hya.!
<br />imliranr tu, a p.mir subjcrrs rhc rprli(anr b r.ivilpcn.[yolmn mo!.llun nvc nunJEd ']oU$ (S500)
<br />-1,
<br />as owmr oi lhc pnpca y, rn my cmphFcs qilh w!8.\ ns lh.ir sdlc cdmtcns$on. wil do lhc work url thc sln'urw ( hn
<br />d.nJcd or oliarcJ lhr $k (Sa.?044- Bushcs and Pnr!$6ns C*lc: 1 h. Conr.ktx s l-idnsc Lrw 'lds nor lPply &, .n .wnc! of
<br />rhc pnpc.ry *ho 6uil'ls or !n !,vcs rhcmn. oJ wh) 'l{rs su.h M)!k h,ns.llor tuMllorrhn,u8h hn orhfown cnpk)yccs,
<br />pn,vx,cd rhal su(h npn,rmnh e n, inrcnLd or oftLrrd lbr qh. tl lr,*crcr, (h. ttrdlae .r iqDvcmnt N sld wilhu onc ycr
<br />ol ontl'hrbn. rrr Own$ Buitld, will havr rhe 6ur'lo ol pruviry thar tu or shc Jil mr hri! or iryore tnc popqiy Ior rlE puqic ol
<br />l. is.wncrot rhc !()F.ny..f,cxclulvcly ront..r'ng w h l'(n*d conkd.rn ( o lonstd.r rrr tDFd (Scc 7044. BusuEs
<br />afir PnnasiD Cod.: 'l hc Coniradtr's t-irensc t-.q noes norapply nr anowncr ol pnlpcn) uh{,l,lildr or impovcs rh.rcon,
<br />.nrl who .ontrG tnr ruch I,U!G wnh , clrnrh.k (\) llccn*d pu\u,nr h thc Contactr -r L'ccn\c Lawl
<br />D&le- Owne
<br />lvaatrEBg.tcallrjNtAlo!
<br />IJEI!,A8AI]O!
<br />I hcrchy alirmundcr pcnalry ol pcrjury oE ofrhc touowine d*ldrionrl
<br />_l hrvc ariw'll N3intiu r Ccnili.3r. ol Conscnr t) S.ll:lnsurc lbr workcr'.ompcnsarn,n. as pn,vklcd lorbySccrDn l?t{)ol rh.
<br />Lahtr CoJc. ktrrhc p.nnnnrn.e o, rhc work lt, *hich ihc pcmrir i\ issucJ
<br />I hrvc dnd willErrrd,n workcri conFns.r n in{nicc. r\ Eqxn.d by Sccr (,6 1?0O of rhc tjhor c(dc. tir rh. p.rli)muk_c ol
<br />rlE *.rk lo *hrh thk pcm ,s 6ocd. My workcB' corp..\nrn nNmn c ..Eicr d poliy numh.r a.
<br />Poli(yNunrbcr: Exptrcs
<br />I.cd'lyih.r Drlr frrlorfrdnrc (n rh. w.rk 1,r wh'chr,n\P.rnur r\ '$!cLL I stull nor rn{L,y.nyl.rnr
<br />'n
<br />rnynmtrD.r
<br />sr 0r b t'c!r,nr $Uc.rt) rlrc wor kc! ( uonrF*nsnridr lnw\ .l arl'Lnrr, .trJ rsrc rhnril I dDul.l hc(,k- qrhjcd n, rh.
<br />workcn cdmncnslri)n povisons ofSc.non 170(r.l rhc lrhtr Cotlc.I drll. t]dhw[h (onDly with rhoc pn]vNo.r.
<br />WARNIN(;: Faih'm b {(uR *or[cn .o'np.nsrion.ovcrec is unlxwlnl. rJ \hall subjc.r rn cnrpbys b crimind tktulr*\,nd
<br />c,vil fir\ ut (,.ru htrndr.d rh.u\rnd dolhn (lsllx),(Xxr. i. rJdirk,n n, (hc co( ol conJin\rrn'n. d,ndpc( !1pn,vil.d turrhc
<br />s.crirn 1076 ofrl{ tf,txtr cul., frcrc{ rnd rrbmy \ rcc\
<br />Dal.:_ ,{pplao.
<br />qox$auquoNrENlBclc.ENq
<br />I h.rc6y rritm nft.lcr pcnalry ol pcrj(, rh rncrc is r cl,Ntn,crnrn hndnrs aecncy nr lhc pcrlnrnDre ol rhc work lnr which rhir Itdir h
<br />issucd (S.c. !097. Civ. C.).
<br />AEELICANLIESAAAIIAN
<br />I tErhy iltim undcr pcnlhyotFrjuryonc.l'hc lollowin8 ilcclar.t.n\:
<br />D.mltion P.mn\ Arb.ios Norfi.ahon Fcd.rrl Rqrlarins (T L40. Pd6)
<br />Rcqur.d lxrr.r ot N,ndiutiln
<br />lnlli(anl 0r Ascnl Sirnnture l)alr
<br />Set Backs z"z-/1 t lk|,
<br />Forms/Steel/Holdowns 2t-tq
<br />Erection Pads -A
<br />2,-7'11 bwc
<br />SLAB Floor W
<br />Sublloor/VenVl nsulation z-t3-/1 V"WIA
<br />Roof Sheathin s 3-15-/9 'ir"Wil;
<br />Shear Wall 3-lt-/hl
<br />Framing 3-2.-t6l uwlm
<br />lnsu lation/Energy J-21-11 wwffi
<br />9,rvwall 1-1"t9 k"w,Nftllnl atn \-l-lf ffi 1-tt-/1 V"rW ))
<br />Err6wY Coat 4 -il-11 gatb&
<br />/zatl<*+-4-n tr-t[Ml
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />I
<br />FINAL 6-1111 V"Vltt,
<br />\)Certilicate of Occu ancy
<br />Note s, Remarks, Etc.
<br />t COMMENTS
<br />latrrcrcnrpl undcrs..rion a &PC.lnrrhsrcr$n.
<br />IICENSED CONTRACTOR
<br />DECLARATION
<br />I hcrby afllrm undcr leMllyol pcljury lhll I {n li.cnsd undcr tbvl\ion orch.ptcr 9 (.ommfrins wirh Scclion 7l]O0) orDilnion.l
<br />ol thc Bnsincssand PDfcsonsCodc. and my lecns. r f tullto(tNl.lft.r.
<br />Li.chsc CIrssr License Ntrnb.r:
<br />-
<br />-l
<br />ccnilrrhd rhc ridcra I r.go lar ions rcg,.Jing rstcnos rcfr)valarc mripplf,rble t' rhB l,miir.
<br />-lcenrtyrl
<br />l n.vc rcn! rhn applicarbn dJ (arc nrr rhc nh,vc rtormrnr h concd I aere n, uonply wirn 2ll Ciry rnd Cornry
<br />orJBrnsandSrrrctiesElaiin8bbuildin8conndcron,andh.!.by3urlDrurEprcsc.ii!€rolrhnCiryMdCounryro.nrcruponrlr
<br />ah'vc mnrn,ncd n$ncdy n)r irs D.ul n, n purrDsc s.
<br />UFER Ground
<br />I
<br />Pool Fence
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