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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Formsi Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenYlnsulation
<br />Rool Sheathino
<br />Shear Wall
<br />Framinq
<br />lnsu lation/Energy
<br />Drywall
<br />Brown Coat
<br />lvlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />FINAL -?17<ltfl -T1rl?2
<br />Certilicate of Occupancy I
<br />Notes, Remarks, Etc
<br />4
<br />OWNIlR AUILDER DTII,('ARAl'ION
<br />I hcrchy .ifirm undcr pcnilly oi pcrjury rhsr I afl crcarpr fr.rn rhc co kn.tn- l-i.ctr{ l,{p irtr rhc i)ll(,*ins rr?sr (sc.7).ll 5
<br />Bu\irc\\ ind Pr.fesion Cdle): Aiy ciry or Counry whi.h r.quirc\ | If,nnir lo .otrNnrl. lllcr. nnnrcvc. dc dhh or rct,.ir rtrv
<br />rtucrdrc, Fi{n ro irs isurrrc.ilsorcquircsrhc{pli.mrfirsu.hNrnillolllcrrigtrcdnlcnrll rhd h.orslE it licc.sci lurtrnnr
<br />nr lhc provnions oi lhc Conrrack' r l-i.di\cd lru (Chj|ncr 9, Co nnc .trrg sirh Scdiotr ,(xx) oi l)ivirt)n .l orrh. Bu\ilcr1 ,trd r
<br />.mli.nirforaFnnirsuhrcchthcrNlicrtrrtoicivilEnrhyofnolnxxthDivchdndrrddollrB(S5lD)
<br />L rs owncr ol rhc tmrny. o. nrycmplorcr\ sirh sascs rs rhrt $lt.odrn n\rri(,r, *illdo rhc wllk Md ltE {uiuru i\ i.r
<br />inrcnd.d or offdrcd fd vlr 15( 701-,1. Bu\ircs nd Ptufc$nrns CGlc l hc On rucnr'\ , -icci{ u* d(8 nnr 0t y r.' to owNr oI
<br />ihc p'.,rny Rh) builds or i'n[.\r! rtEd)n. d wh.dftsskhq.'kh nsclt!rhcrclforrhmulhhko.hcro*ncn[k,ycc\.
<br />rovidcd rhlr such impmvc,Enk m nor inrcndcd or odcrcd lnr \rL l( howcNr. rh. lailLlirg or impn\$Enl is \rld *irhi', onc ,t!r
<br />of corrll Lri(,n. rh. Owftr auiucr rill harc tlt bu cnol[ovin8rh ttor\hcdilior buik] or nntmlt rhc tmpcny lbrrhclunn\coI
<br />l.dsowmr.frhcFro|xny-rrcxclusivclyconl!i.ri',crvirhli.cnnatro rr.ktr\k,...{n(r rlErn)jcd (Scc 7t}lt, Brnm\s
<br />rnd t,I.rssbn A)dc:1'h. Conta.ioas Liccnsc L.w des nor inrly ro rn os0cr olnrop.nv $h(, huild\ tr Npn,rcs rhcrcon.
<br />r.d wno.onlnclslorsu.hfloj.cksirhrConkachnrlic.n\cdNi\xniitulhcCont!.!r'\Licctrql,1qr
<br />I rnr.xrmB undcr S€l ll & tC li, r[nrcrlnr
<br />TAX&:f,IIAMTIIjSAIIQN
<br />DECI.AAAtrON
<br />I hcrcbydl'i nundcrtcnallyol Jrc.juryoncolrhcfoll{nrin!dftlrrrii,,n\
<br />-lhavcMdeillminraina
<br />Gnifr0rc of Conscn( to Sclf.lnrurc rbr wortc comrcn\rrbn. rtuvdL{torhySc.lion37OOofrhe
<br />L.ho, Codc. frtr lh. p.rfomftc of I hc s.rk f(n ulri.h rh. I).nnl h n$&l
<br />I hr$ rnd willmridrin sorkcrr cornFnsllion inslnmc- $ rcquircd 6ySc.rn l?mofrhc t hot Colc. Inrrh.ncrfoi, rtrc.ot
<br />rhc $nrk for whichthis pcin r is ksued My*orksi conl[rcn\aiioninsurrn.c..ricrafr,rolicynunhcr {c
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<br />ccnify ihd in rhe pcraormrn.c ofrhc work fd whi.h rhil |)trmit is nslcn, I rhull mr cnrkry any l.r*r irr !try mtrNr
<br />$ ,s ro b..om subjer ro rhc wo cc comr.ns,r ion ltr* or Crl ornir. dtrd rgrN rh.r if I sholld hctom uhicd kr rtf,
<br />worke6' $mp.nsar ion pmvisn,ns ol S*rbn .l?(x) .f rhc ljhr C lc. I .hrll. ionhwirh comply $irh rhoy F,visn,ns
<br />WARNINC Frilxrc io quic mrkcn' comFnsol ion covcr.sc n unhxfrl. lnd \hrll \rhid an cmpk,rcr lo aimiNl pcMiric\ did
<br />cilil fi cs u, r. onc hu.drcd lhotrsond dollm (S100.00(D.tr dirion b rhc co{ of.on1Ftrs.r(nr. dr nr8c! r\ nn)vid.d nr rhc
<br />SNri,ni rl)76.f ihc l-ilt
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<br />ITIIIIBAIION
<br />I h.mby afii.n undcr pcnally ol ErJUry rtur I om liccn{n undc. pmvGioo orchaprd 9(.omnrmin8 wilh S(rinr 7(xDl orDivhio.l
<br />ot rhc Business and Profe$sions Cod.. dd my li.cne h in tull lorcc und eff.cr.
<br />coNuf,uquaNlENDtN ilNq
<br />I hcrcby aflnD undcr lcnilryofpcrjuryrhrr lhcrc h a coi(tu.rion lcnJin8.8cn.y lar lhc |riiiru,ncc orrhc work itr Nhich rhh l4 nrir h
<br />ksucd (Scc .1097. Ci! C ).
<br />Lcndcls Nonc:
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<br />A.tluQtNflrE;LAaauoN
<br />I llrcbtaflnrundcr Fnnlryol pcrjuy orc olihc l',)llo$i(-s dcclrdnnrl
<br />Dctrlrlilbn Pcirnirs A\b.{.s Nor'n.,rion F.dcitrlRcCuhrnnN fl ille 41r- Prr6)
<br />Rcqun d LdlerolNolilErrion
<br />l.rdil'vrhrl I h8c rciLlrhirrpfllcrri,rr {rrrrhnrrhoxlxro iintr hridrr(.orrccr ltrSrcckl
<br />nrd,mrccs and Srdrc trqs rellrinB ro build y urrx,nzc rctrc\cnlllncs.ll
<br />rt{trc Rn.oncd |'o|dr,
<br />]\ppli( nl fi ]\Aetrl SiAnilure
<br />LurLlfl
<br />conDly eirh rll Ciry.trd Cotrnry
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<br />II
<br />Ext./lnt. Lath
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<br />_lccnilyrhxrrh.lttlcBl'.!ul i,ns rcB direr(rnosrcnNvrldrc nor rptlicrhlc t, rl,i\trRic.r
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