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BUILDING- INSPECTOR RECORD
<br />-SITE-WORK DATE ID/SIG,COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Boof Sheathinq
<br />Framinq
<br />lnsulationi Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Ceftif .
<br />, )"4(ofrLtu.n/b/Arr#FINAL -.vWL .t-n
<br />Certificate of Occupancy V
<br />. Notes, Remarks, Etc.I
<br />L
<br />()IVNER aUILDnR DEI-CAR-\TION
<br />I hcrchy rlttm undcr Nnrlly ol Fdury rh{r I am crcml rioN rhc (nntrros Liccnsc l-as r'or thc t)lk,*ins .cron (sN 70.11 5
<br />B!\incs\ md ttofcsion Cdc): Any Cily or Counly *hi.h rcqunc( r lcirnil ro con(n,cl- llrcr. nnprovc. dcnolith .r tprr riry
<br />{fl.rur., |)rntrb irs isuucc. il$ tuqut s rhc +plicrnr f{tr \uci Frmir b fib! \i!kd { d'ft rhai h.or shc il li.ctricJ |DFua
<br />nr rhc pn!isions oi rhc Cotrlrrctois Li.cnsd Lr* (Choplcr q. ConrnrncinE wilh Sccrion ?(xI) of Divi!i,)n .l orrhc au\nt\r rnd
<br />Pn,fcssi{,trsCod.)orrhrh.orshci\ck'nprrh.rcfr. lnd rhc br\i\ tur rhcsllcecd cxc rrrioi Anyrnn.rionofsccth.?0.11 5h}nny
<br />rptlicatrrror a Fcrnrir sublc.hthc nmli.anrlo!civilI]cnrltyornormrclhanlivchundrcddolhn(S5lx)).
<br />l.N own.r.frh.pbl. y,or r! cnDloyccs wnh wrEC\ !s rhcir n,lc co'np.n\arion. will do rlr *o& ,xl rlr sMlN is n,
<br />n'lcmlcd orofltrcd rbr slc (S( 7t!,,1. BusiDcss and Pmlc$idN codc: rhc co racrois l,i.cnsc tnw docs nol ryply b an o$rcr.l
<br />rh. pn'Fny who l,tilds or in{nM\ rh.tu . md who d€s \!ch *ork him\clf or hcnclf or rhn,ugh hi\ .r hcr a*n cnplorccs.
<br />provtrlcdrh.rsochi,npiovcrnrsnrn.ri'ncdtdorolfcR]iffsLllho*c!er.rh.huildinsorinyn,v.,fttrrissoilwithinoncrrr
<br />orc.'idcrion. rh. ONncr BniHe. *ill hrvc rhc btrdcn ol pmvin8 rhd tE o. \hc did mr hoild or in{"olc ih. pmpcny lor the ptrrF){ of
<br />l. a\osicrolrhc prori.ny. a,ncr(|tr\nrlyconrrucrins wirn liccnscn conrrdo^ ro c.n{ru.r rh. pbicr (Sc 7Ot1, Buucs
<br />0M hoissirtr Codc:1hc conr0dols l-i.ctrsc tis doc( tror,prlyt,,trow d orpropcnywho huildsor mprcrcs rhcrc.n.
<br />and *ho conhcr ! ior such pmj{k wirh r Conklcro(\ ) licc.scn pu$lanr ro rhc (t nhcroi s l,iccn$ lle )
<br />I xrc\cnrtrr trfdcr S.crior .ll &l'( l,trrhnr.r\n,
<br />l)nl.:
<br />traxa!:B.ur(,)!tr!N$.ara!
<br />DICLASd.IION
<br />I hcrhyrfin.rx dr p.dalryof Frturyoi.of rl[ftnlo*nr! dcclrrrri(nr
<br />thlrrtrdNillnBinriinrCcniliurcofCooscnrroSclflnsuEi,{.r[c o'nncn\dn r.J. p(rvidcd tur hyS&1id] l7(x)ol lhc
<br />l,hrC c. ntrlhc ncrionn!trccol'lhc sori lor whichrhc tonrir a s\ucd.
<br />I ha!. nnd willnri nir $ork.r! .omFn\rrii in\urxicc. r\ rcqtrncd hyS..rii ]Tmulrh. trhorCodc. Inr lhc pcrionmNc ol'
<br />drc $.rknn$hichihnn nn ,\ G$cd My work&a ..nrpci\lnnr nNU n.c.rfticr dl[li.yfunrbcrrc
<br />-l..nilyrhar
<br />in rlrc I)crlhrnEn.otft work lhr shicnrhis lEnnir is ilrucd.l shrllnor.n,rnorad! pcNnr irlr y mtrtrncr
<br />s) rsio h.co r \ub.J..r ro rhc wotkcr .o'nNns on hws .l Cnlif,nrir. md iBrcc thit iil should bcc.nrc $,hrd blhc
<br />workcis c. rlcrs ri( frovisi.ns.fS..rionlT(Ddfrhc l- hnGxlc,l shdil, fonhsnh.o.!lyuiinlho$nrorniotrs
<br />WARNINC trilurc k, Errc workcA' c.nlpcnsdtD .orrx'sc is uh*idl. and (h.ll \ur,i.r M cnrtlo)tr ro anniNl Fntrlri:s aM
<br />.i!il tinc\ ut, loom hundrcd rhouund dollsr (Sl00.lro0). if (ldirion t) rhr ro( or.onlrcns,iiotr. dnnx€cs.s providcd rbr lhc
<br />,,sh: ?/s/,Y.,uu,,,,N 4--Z-
<br />Lr al a\r .p (itrN r R]\c I ()r.(
<br />o[ct Aaa.rla!
<br />I hcrcbylmmunlcr pcnalty ol rcrjury rhur I am licen*d uxlcr pmvnion ofchllrcr 9 (conftn.ing wirh s..ri.n 7s)0) orDivtiotr l
<br />ol lhc Bu.incs rnd Pr.fcssions Codc. nd my lic.ns. is in rull rda aM clnct.
<br />i2t>QToa>o?/slr)'-"'-.*\-L'4-
<br />taNrBlErll)Nl.lNDtNc-acllLt
<br />I hcrcby atfirmunder pcnnlryolpcrjuryrhlr rhcrc h a connruclion kndins a8cncy fttr rhc p.ri,nukc orrhc work fot which rhh lisnir is
<br />is!'crl (Scc .10)7. Civ C.r
<br />lxrJ.r'! Nx r
<br />Aftuc NLDECI.ASS.IIQ!
<br />I lm$y arljm unds pcnolty or p.rjury onc or lhc lbll,,win8 dcclrnrion\
<br />l)cmolilion Pernril$Asb.(os Noriliqriqr lcdclal RcEuldio.s( lirlc.l0. Prn6)
<br />R.quncd I c(1crrf Norillcrri{n,
<br />I c.niry lhdr tlr rdicnlruSulalions r8ddin8 ash.sl.s r.DFvnlar. not iptli.rblc to lhk ptutlrt
<br />-l
<br />ccnify rhal I havc rc.d rhh rpplic0tion ond {are thd thc &,vc innxnmtiotr iscorur I ism
<br />'o
<br />comply Nirh all ciry rn'l G)ntrrt
<br />odina.ces ind Starc bws rcbtiu to huildin8 construcrion. ard hcrchy urhoriz. rcprc*ntlri'cs (,frhn Ciry&d Coonry ro cnrd uFn rlr
<br />ot-\c nf,rr'oncJ tmFny lor 'nlnNrnn lurIn{\ _a ,/
<br />\Dpri.or,or{p.n,\isniruft. 4=;t'^'.
<br />P.mlle. n.ne r prinr,: ,{-Qfen I lZaJ:r 4
<br />,,8,e ?y'/'r
<br />Shear Wall
<br />(-r"i,1
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