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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.O1{NEII DUILT'ER DEI,CARATION
<br />I h.nbylrtrnu cr p.nahy ol Frjury rhrr I.ncrd rnr rmm nr conkNion Liccns l-aw lor rhe rollowine rcastr lscc70115
<br />Busircss md Prolcsion Cnrc): Any Ciry or Counry which rcrlutcs i rmil ro $nsltu.'. alrcr, imprcvc. dcDmlnh ,tr (nJn M,
<br />srfl.rurc. nritri. irs issumc.. rl\o rcquncs rhe opdicanr lor such Fnnit io lilc a ti8trcd srcnror rhar hcot shc n lienscd ruBUMr'
<br />ro rhc Invtions ot rhe Conrr,.tr's Li.cnsd 11* (chrprcr 9, co.rnrcncin8 wilh s..ri.n 7(xD .l Divisiotr 3 oI rhc Busincs ud
<br />Piofc\\ionsCodc)orrharhcorshcisexcmpllhcrcforondrhchalisturrhcrllcs.dcxcnlrion.AnyriohrnrnorS(rbn70ll5byd.y
<br />spplic!trr rbr r pcrnrir suhJ.cls rhc rtpli. nr ro acivilpcralryornor mrc lhan fivc hundrcd d.ltd\ (S5tD)
<br />l,.so*rf,rorrh.trc|).ny.orflrycnul.yeswirhraBcsr\rhcirvnco'np.trldrn.nilldorhc*ortuxlrhc(durci\tr.r
<br />iendd.rofilEd,orsle(sa7044,arsinc*nidPtuIcssion\G)dc:TlrcContrcr{tr1t-icciscl-rwdocsnorlPPlyroano*ncrof
<br />rlr fn)*dy wltl blilds or inDrous ihtr,n, ud wlb de\ shh so* hi'n.cllo! harcllor rhrcoBh his o. h.r o*n.mploycc\.
<br />[ovidcd rhrr such i'np vc,fttrhdrcrotinrcndcddoflcrcdlorsrh.llhoscvcirlrbnildirsorimProvcmnrirsrk]wirhirotrc)t'd
<br />olconllhri,n. rhc 0$ncr BuiUo sillh3vc lh. hxrdcn otpovins rhar h..r shc did ml hlild or imFrM lhc lln)p.iy tor rhc PurPror
<br />I. x\o$ncrotrhr!n,Fny, rDcxclu\ivcly.onnadirswilh liccn{Jconta.rt\ro.onnrud rlL rrqccr lse. T(U4. au{ftls
<br />.nd ftDlasdr G)dc ltuCotrlracrofs l,iccns.l-sw doc\ iorrlflyt, itrowtrc. oltn,ncnywho buildsor nnlrovcs thcrcon.
<br />rnd $ho.onrr!.hlbr\u.hpuc.BwfhiC-onrmct(rliccn{dturru k, rh. conttrn-s Li.ctr{ trw).
<br />-l
<br />rmcrcnr|n undcr S..rir ;;,L
<br />DECLABAIIQ!
<br />I hcrcbyrflirdund..l.n,lryorpcrju.yoncoflhcrbllouin8dccl !rion\:
<br />-lluv.,ndwill'tunnain,Ccni-EalcofConscnrloSclflosurclor{orkc^.otr1Fnsdn,r.os!rctiJcdnrbysccrhlruooilh.bbor Codc. Inrrhr p{rn]rmnccorrh. sork lorwhich rh. pcrmil i\ hsucd
<br />I hrvc !to1 will nDntuir workcrr conDcns ioninsurrnc..6rcquirudhySRrio.l7ll0olrheLahorO..fttrrh.pcrfonmrccoI
<br />rhc work rorwhi.hrhi\ p.nn[ is nsu] My $orkcF .onDcNrrion insum .c.rnicr mdn licynumhcrac
<br />I c.nili rhrr in rh. pclromuN ofrhc work rU which rhn pcnnil i\ i\\ucJ. I rhrrl tro' cm oy rry Pcrsoo in rn, nrni$
<br />\,Nr't*&ncsuhjcdlr)tltworkcs'compcn\ulionlaw\ofCrlil{trnin.dnd+rccthdiilshouldhccomc\!hjc.rrolhc
<br />s.lkc^ c.mpcn\aL.n [ovisions olSccrion:]7(Dorrhc btitr C(ldc,lsh.ll. rhnlNilh conrtly wiln rh,r,)n,vhios
<br />WARNINC ltilurc ro scurc workch onrpcn{ ion
<br />civil finc\ up r,) otrc hundr.d rh.usan,l dollas l$Ifi
<br />Ssrn,tr 10?6 o{rfic l-Itnr Cdlc. i .rcs and ntronEy\
<br />D5tc: applionll
<br />\rr lr (i'ni0rl t{Drllc\ rnr
<br />DFCLARATION
<br />Ihcsby,mrnr und.r I'c.rh, of!.rjurr rh l ah li.rnsd undc, F,vniod dl Chnttr 9 (connmmios wirh Sc.rion 7(fir) ol Divhion .l
<br />of rhc Bosincs dd Pr,rcssions Codc. d rylicctrs n in lull (trcc rRlctlccr
<br />C(INS'I'RUCTION I FNDIN(i A(;ENCI
<br />I hcrchy rfilnurdcr Fmxyorpcrjury rhnr rhcrc is r..triru.lion h*lins ngcncy n,r rh. lcrlonrm.c olrhc work lor *hi(h rhn Fnni' i.
<br />isrud (SLr 1097. Civ C ,
<br />ATTUCAIIDECLIAAII9N
<br />I M), anim undcr pcnnhy ofpcrjuryonc olrhc n]lk,$inB dc.lurrion\
<br />l\nx,lirion P.irtrir\ Asb.(os Nolificnrnrn Fcdcrul Rc8uhlions ('lnb40. Pd6)
<br />Rcquircd trtr.r of NolifErlion
<br />l.cnifyrhrr rhc l8lcol rc8ularions Eg{ding t nosrrn$hlrc trorr|fli.$lc h lhi!tnttr
<br />_l ccdiiyrhrr I iBvc rc rhi\trpplicarioi flrl Narcrhd rhcnhovc innnnDiion is.orc.r.I rlrN I
<br />i{-'rJrcc.JnJ qr r I rq. R Lrrp r. hL'UIc !on.rru!h.rttr'J hc'uh) JUrho,r. '.t'."q1.rnc' "l'dh.\c
<br />'mnrunc'r
<br />nromnr t! in / J ,
<br />n*,**, - o*"*,*.,*" l@-al/ loq* [<"''
<br />o omdy *irfi allCiryand Counly
<br />rhh Cny and Coun'yro cnld ulrcn lhE
<br />Drl.
<br />-
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf looriVent/l nsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsulation/Eneroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />ltilaso n ry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Ir -11
<br />FINAL rl tlltt Y(fl16o,ft tw
<br />Certiticate of Occupancy ' I /' rl '
<br />Notes, Remarks, Etc
<br />COMMENTS
<br />ol conl,ri\rrnnr. ddm.gcs !\ jno!i,lrd tur r[.
<br />%*rzl.'
<br />l-iccnsc Cla$
<br />-Licctrsc
<br />NumtEr:
<br />-
<br />Dore:- Conhdor
<br />Lrndcia Addn\
<br />-
<br />Forms/Steel/Holdowns
<br />Pool Fence
<br />Flood Zone Certif .
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