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BUILDING- INSPECTOR RECORD
<br />SITE-WOBK DATE ID/SIG.COMMENTS OWNER BUIT-DIiR DELCARATION
<br />I hcrchy rnirn under pcnalry ,)r n{rjury rh,t I !n cx{mpl imm inc ConlrucxrF Li.cns. Li* ror rhc iollosins reav,n (sc.70ll5
<br />Blsincss lnd PRrrc$ion CLdc): Any Cil, or Counly which rcautcs a |xrtuir k, (n$rrucl. 0llcr. inprclc. d.nrlh[ or rcIln rnv
<br />{ncrurc. trin r. irs issud.c. sle rcquircs lh. upplicanl ror s!.hFnnir ro fib! signcd slalcnEnl rhar horihe hJienscd lusuanr
<br />ro rhc ,rovnions nl rhc C.nrlcroas Liccnsed hR (Chrrtcr 9, C.mmcming *irh s..rion 7uxr.f Divnion:l of(hc Susincs rnd
<br />Pmfcsiotrs Codc) nrIhlt hc or shc i\ ci.$pr rhcrcliod md rh. b3ris fo. thc 6llc3cd crcn{rio. A y viohrionolSccri.,oT0ll5 byan!
<br />applictrnr lu a !.!nrir subj(hrh. Vllicotrr lo ocivill[Mllyotmrnffcrh,n fivc hundrcddollds (5500)
<br />L !s osncr or thc lmlEny. .r nry cmpk,y.cs wirhwslcs * rhcir $lccoDPcn\dion- uilldo rb. work.nd
<br />'lF
<br />(ulm t n.r
<br />inlcndcd o,oficicdfo!{lcISL{701.,1,Busirrcs0ndftonssionsCodc'lhcCo.t tr\ Li.ctrs L{q nm\ nor Jrdy lo ,n owncr ot
<br />rhcrmldy who huilds or iq,mv6 rhccr. md qho d(B suh worl hinr.lfor h.rsclfor rhou8h ht or h.r o*ncmplovNs.
<br />Iblid.d rhar skh inpmvcnEnls e nor inlcnd<l or ollcEd f{tr slc It ho$crcr lhc buikling or iryrcwnrnl is sld wirhin onc )ttr
<br />olconlphrion.lhc Owncr Builiid *ill hvc rlI t Rlcn of pmling rhd heorsnc dii e, buiu Dt nq,oit lhc PDP.iy t rrh. PuqrEol
<br />l. N ownrr or rhc ,r,t,M,. !Dcxclusivclyconrrlclin8 wirh licci*d .ontr{.i.n ro con{dcr rhc Ft,Jcd (Scc 7014. B!\io.s
<br />nrt ltofsshnCodc:'t hc Conta.ttr \Li.cnsc tj* docs olnptlyloano*ncrorlnrncilywhohuildsorinrpovcsrh.rcon.
<br />rnd who c.ntrt tur su.h prcFls sirh ! Colrrcxtr(\) liccn{d nuru.nl lo rhc ConrBc'ois Liccnsc rrw).
<br />I rmcxcnpr rtrd.r Sc.l*".Q-t{-tY
<br />I)!,:EI AR,\ IIIIN
<br />I h.rcby rllirr un,lcr |tdrlryof|[rltrryonc ol rhc lollowirB dccl4xinnrs
<br />Il[vc!dwill'nrinroirtrCcnificrrcolConsctrrbSclflnsurcntr\orkltsontPcnsrrbn.rpn,vidcdforhySccrn,n]7m.frhc
<br />trt-r Co!.. ror rhc p.rtu.mn.c of rhc $olk ior which lh. pcrn,ir i\ i\\trcd
<br />rhc $ori l(trwhich rhi\p.nnirir nsad MysorkcrJ co r$nerion irrstrrr..trri.r (l FltrJ_ nu Nhcr ar.
<br />Poli.y Numb$:-Exp
<br />Iccnilirhar nrIhc lcrrofln'ncc oi rhc *ork lbr whichIhi\ pcrnn ir i$ucd.l rhrlltror cnrPbysnyl.r\ inan,monncr
<br />s as ro b.com subjd lo lic hrkc .o'npcnsdion hws oac0lilbirrir. and trgruc ihrl if l should hetomc suhFd ro rh.
<br />qorrcn co.rFns.lionpn ionsorscdn ]7morrhc bh, C'odc.l stsll. fonhwirh .onDly wirh thos pmvisions
<br />WARNINC: Flilurc t scurc workcE ompcn ion.ovct{sc is nnhwrul. aM shall subicl an cmploy.. ro oi,ninnl Penohi.s mn
<br />kr orc h!.dred thousand dolles lsl{xl.t{Ij). h addnnr" ro rh. cos ofcomPcnsli.n. da@8.s .s rrovidcd ir lhc
<br />Sc.ror ll)76olrh.l rtttr Codc. nrurnnDd
<br />DII!/!&!I.LD
<br />I hr'.hj- rllnmu d.r trmlry.l|{r undcr f)vnior ol Chirrc!, (comnf,ncing wirh Sccliotr ?$10 ofDiehnt I
<br />oi lhc llusincs\ rtrd P(,fcs\n,n\ (bdc. irrd myliccns is in aull ftn.. afrl rlrccl
<br />-" 4-11- IY (.rhc,.r
<br />STJ,IJAIJCI]ONTENDTdCIAENCI
<br />I hcEby alnrnu.dcr rEnahyofp.rjoryrhat rhde is a connrucrion hndirs ascn.y io. rhc tElonmmc ollhc wor* for whth rhn I)e mir h
<br />issucd(se 1097. civ. c )
<br />A.STLLCANLDECLAI{IION
<br />I ho$y nfllrm u ftl$ pcnilly ofperjuryonc orrhc rollowirg dc.ld,rtuns
<br />Dcm,lirion Pernns Ash.sos Notincarion fcnerul Rcsulationl (Tirl.4). PM6)
<br />Rcqutcd htr.i ol NoIff,olbn
<br />lcdcral rcgx trr io n s E8urd ing ostEslos rcnrolal arc nor lpplicrblc ro rhisl)loFl
<br />lnncl. this rpllirri.i md nrr.rhdrhcahtrc i inndiur i\cotrccr IrSrNr.conrPly!ilhlllCirytridCouflly
<br />r(. I r(\ i.IrinB k] hn,Ldi'rg (oDq,u.1(i. xtr ruthori.c rcprc(nhrircs olrhh Cnyond Counry kJ cnr$ u|rcnrlx
<br />"-,._lu
<br />lZ,nrl ^,",
<br />q.-lt-lY
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf looriVenVl nsulation
<br />Rool Sheathino
<br />Shear Wall
<br />Framino
<br />lnsu lation/E ne rgy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />lvlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL I t-// - /9 t>CrV)
<br />Certif icate ol Occupancy
<br />Notes, Remarks, Etc.. // ^J/^ / ) >',-.-<
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<br />Forms/Steel/Holdowns
<br />/.atz
<br />*",Q- tt--Lk
<br />L,' "lr' . AJJ'i$
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