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BUILDING. INSPECTOR RECORD
<br />DATE ID/SIG.OWNI1R BUN,DTi DOI-CARA'I'ION
<br />I h.rchy alfinn rndcr !.nrhy of lcrjury thd I un cxcmrr riorn thc Contr{rua Liccnsc uw rar rh. rolkrsirr8 r..bn (Scc 70115
<br />BusnEsr and Prolcsiotr Codc)r Any City or Counly l'hich r.qutcs r Fcnnir io conq .r. a!rd. i.Dmrc. dcmlhh or EIon lny
<br />strucru\_. plior h ns hsulncc. ale rcquncslhc lnplicanl lirr such rcnnilb fi|., \iSncdsr,rcnmr rhar hcorshc is licenscd pursulnr
<br />lo rh. p6visi,,r\ drrh. Contm.ror's Liccnscd Las (Ch3/n 9. ComflErcnr8 qnh Sccrion Tlxll of Divnn'n I ol lhc Busincs ind
<br />PrcrcsionsCodc)orth0r lE or shc hcrcnu,r lhcrcflomond lhc brst for rhc allcEcd crcorrion. AnyviolarionofSErion 7011.5 bylny
<br />attlicrnt iorr ltcmir subjcchlhe applicanl rorcivilpcnrhyotnor er. rhai riv. hnndt ddollds(S5ml
<br />l. A o{n* of rhc pnrtEd!. or my cmplo}ecs {irh wa8cs as lhcn {,b compcnsarn)n. will do (h. wolk Ilhcslrcr@hnor
<br />inrcfth or ona.cd lor ek ( S( 7(}14. Busin.s\ rld Prorcs\i.nr Cod. l hc Conricrois l,iccnr Law dcs nor ,prly ro an osNr or
<br />lhc0mFny who huilds or in{nns lhcNn, dishrdms\khklrt hn$clfor hcrslfor rhn'u3ihnorhcr o*ncnlloyccs.
<br />prcvidcd rhnr \uch intruwmns N fr, inrc*ld or olTLrrl foi slc. li honoc!, lh. huildnE or iaryotnrnr ir sB wnhi. onc )Mr
<br />of.onrrkrinl ll.. osncr Builds will ha'! lhc buldcn ot DmvinS ltu hc or shc drl ft,| blikl or i.{mw rh. ImFiy for lhc puqrs oI
<br />_1. is ownc'olrhc F,p.ny. r rcxclusnrly.ofta.rnr! sirh li.cnscd cotrorcroF l. con(rucl rhc pmtccr (S( 70r-r. BunN$
<br />kl l\oLssftr Codc ThcContr&tofs Liccnsc l-awdocs nor opplylo!no$ne!ofproFnywho buildsot inrPtorts licrcon.
<br />and who c-ntract! t)r such pfl,j.rr\ {irh a Co Ecktrl\)liccnsd pu*urnr rolhcConrlctols Licen$ Li$)
<br />I rmrr.'nJ,r trndr Sccrl
<br />OPne.:
<br />IA8([rU:CArIrnNSIllgN
<br />DECIAIT&IION
<br />I hercty rlli.muder pcnrlry ofpsjry.trc ofrlc nrloui ! drcllrrrn,nr:
<br />-lhrtrlrlwillmrinrainaCenificarcofCon\c
<br />rosclat.\urcforuorkcdconDcn$tion.!spmvilcdlorl,ysN!ionl?llo.flhc
<br />ljhor Codc. for lhc pcrfonrunc. ofrhc wort ror *hich rhc pcrnr nisu.d
<br />I hrvcmd *ill rinruinworlcriconD.lsrrionnNu.rnc.r\rcqtrircdbyS.cli,'n:lT00.frh.tjhorCodc.forrhcI'caorrunccof
<br />rhc work rrr which rhi\
<br />''.rnnr
<br />is nsucn. My workcrs coD[Ensrtion iNura!.ccaricr ad rnicy nunbcr dc:
<br />|di.r_ Ntrmh.r
<br />-
<br />lif 'r\
<br />l.cnrly lhdl in thc trrrornuncc oflh. *ork fitr whicI rhn rrrn,il is i\surd.l \hall ior cNttlot any nc6on in rny mlnner
<br />{, !sk) hcdrN ubjccr rorhc $orkrl onD.nssrion ldwsorcrlironri( ind 08Nrh{ iII should tEroN $hJcd t) rhc
<br />workcr.onu{nsltionprcvist,molSc.rnnr:lT00otrhctrhtrCodc,l\hnll.i,fih{irhconrPly*ilhlhottnrvnn'ns
<br />WARNIN(; Fnilrrc ro e.urc qortcn comFnsition .orcrasc i\ u.h*f!| rnrl lhrll suhjc.r rn cmPloycr ro crimintrl Pcnrhh\ rdd
<br />.ivil r,nc\ ut t, ond hondrcd thousrml dollm (Sloo.un). ir uldiltnr h rhr cod or.omFn$rnJn, drmBcs is Povidcd ror rhc
<br />s.crn 1076 of rh. uhtr codc. irrlcrc{ nnd nrronEy\ llcs
<br />LI!$LTEDI;!]NIAACIOtr
<br />DICIINAIION
<br />I hcrcby affim undcr FnahrorI'.rjury rhd I am lien\.d und.t provision ofChapict 9 (commncins sirh Skrirn 70m) olDilision l
<br />of lhc Busircss.nd Pmlc$ions Codc, and nyliccn{ n in tull forc,il cff(r.
<br />AITLICANLI]ECLAX{IION
<br />I hctrty rfllm undcr !.n,lry ol rcrjury onc ofrhc l'ollowin8 dalarulionsl
<br />Dc.mlirn,n Pcrmirs Ash.{o\ Mnificdion f-cncr.l RcAularions lTnt 4l- PanO
<br />R.quir Lc(crofNolilicllion
<br />_lccnityrh rh. icdcrul rcsx la r ions rcgdding ash.(or rcnmvrl rr. mr.Dplic lc rolhis !n,jd
<br />snd Cou.'y b cnrc uroD lh.
<br />I.diryrlEr I h,v. icad rhh {,pli.ation ut srtrrc rhar th. ftolc inlhnmrion ncotr cr I dsre ro contly
<br />,,rJ'nrn... Ln,i s'rr. tjtr\ rLlne ro hu'Urnp r^nqrucrnr and I'cich).urlwi^ rcmc\cnrrrrc. f,trhn.nl
<br />ntc mfli.ncd tmncfly |nr insll.dhnnurln(\\ I
<br />Appu,nr d {rmtsr*mlurc F- k2'-:- Ds*
<br />r.mi,enahc,pri ,: y- X'"it( BnaJ
<br />. r/.t!,1rP
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsu lation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsulation/Eneroy
<br />Drywall
<br />Brown Coat
<br />[/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL >./2 i/*, 9.'w 3-l FTLLaA
<br />Certificate ol Occupancy
<br />Notes, Remarks, Etc
<br />SITE.WORK COMMENTS
<br />Ext./lnt. Lath
<br />CO.N,iIBUCIIONIENDIU{i3TiENEI
<br />l hercby rftn undcr pcnllry.fFrjur!rhd rhdc is,.onsrru.rion hndirs0Bcncyforlhcpe irnmrce of rhc $ork ror *hich lhis tf,rni is
<br />issucd (se.l$)?. civ c.).
<br />bdil.''\ N n. _
<br />tl
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