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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE tD/stG.COMMENTS OWNER BUILDER DOLCARATION
<br />I iercby oittm unncr lcnnlry of pcrjury rhlr I am cxcmtr fmm rh. Co"lmclo l-iccnsc tjw for rh. rollowin! tcaqrn (Sc.70ll 5
<br />arsines and Prol.$ion Co<lc)r A.y Ciry oi C.! , which rcqxi6\ r Fmnr b con(dd. dir. inrlrotr, dcmlish or rcp8n lny
<br />{tucruo,IrkJrb its hsu,n.c. , ko rcqu tcs rhc q,pli..nr lbr ru.h p.rmn ro filc a s iBncd ( lte m nl lhol hc.r rhc t licctr{d pu^uad
<br />ro rhe Fsvhions ol thc ConrEcrois Licenscd L!* (Chlprer 9. Comnenci.E *irh s..rion 7000 .f Division I ol rhc lrusirc$ and
<br />Pn,f.sion\Codc)orrhlrh.orrh.is.xcnprrh.r.ironrn.drh.tssiaturh.rllcscdcrcmption.Anyvio,.rion.lSsrir!?03l5bylny
<br />opt'lic0nl for 0 pcrnil suqcclslh. arllica ro acivilFctr.hyolnor mrclhan five hundrcndollos (S5L{))
<br />L a\ owtrcr of rh. proFdr, orm,cntl.rEs wirhugc\i\ rh.t v'lr.uqr-tr\ on. *rlldo rhc *ork !trd lhc slMlrru i\ nor
<br />inrcndcJ or ollcr.d f(tr elc (Sd.7O44. Ausincss md Pn)fcsiuN Codcr'llr Conlrrclois Lircnsc Lr$ &,cs ndrlpnll b.i ownf ol
<br />rhc proprdy s ho huilh or inprorcs rhcE)n, ,J sho dm {cir sorl hinscll or h.^clf or rhn,rCh his or hcr own cnrllorc$,
<br />providcd rhrrsu.h inDr.vcnrnt m mr iorcdcd n olIcE'd ,nr sh li ho*orr. rhc hdildin! or iq'ow'nnr i\$ld within,,nc trr
<br />olconlJLrion. d. Osncr aui0cr will hav. rhc burdcn iil'rrovirS rh h.orthcdidftn$nildori'qtrovcrhcp6!d!forrh.Ptrrt sof
<br />L asosncr.frhc pnlpcdy. rmcrciusivclycontrcrinS wirh lic.n\cd conlnck$ lo connrucr rhc Inojd (S.c 7Or4.3trvks
<br />rnd Pn,li\sbnCadc: The Conrracror'r l-iccnse tiwdoer nor lprlyb "nosndr.rrtupc ywho huilds or imlrovcs thcrcon-
<br />rM who ..nrack ror such rojcds with r Conm.bi s) li.ctr*d puru.nr rorhcConr,acln\ Liccn\c Lis)
<br />-l
<br />ancxcnr undcrSarion-.lt & P.C. forlhtrea\on.
<br />Dlrc Orner
<br />lloR(ERS' CO[tpENS{TION
<br />IECIATAIION
<br />I hcrcby nflnn undcr I'.ndtyofp.rjuryorc ofthc lallowinS dc.Liatiotrr
<br />Ihrvrn *illnl'inrdimccdrlic,cofcotr*nltoscll.ltr$r.litrqorkc.onr!.nsarioo,!slnvidcdr{nhysc.rionlro0olrhc
<br />Lrhtr C.dr, trr rhc lrrf.i,nrtur of rhc woik for whi.h rhc Nnnir is is$rri
<br />rtu worl itr shich rhi\lcnir i\ is\dl{ My *.rkrr' conrFD\rr i,n] i'rurri.c..ri.r rnl |r,licyntrrhcr irc:
<br />Po lic t N! mbcn-Erpncs
<br />l.cnifylh in thc FrloirNrcc ofthc Bork for *fiich thn lcirnit n nsucd, I llurll nor cnDk,y ,ny l.Mn in rtry n'0trno
<br />w!stoh€comsubjccrrorhc*orkers.ompcNarionhFsolcoliftniirridagNrhariflshouldbccomsuhjccrlorh€
<br />*orkcrs compcnsarionpmvisn,nsofSccrn,nl7(nofrheLatuCodc.lrhsll.ronhwirhsnrplywirhrh.sprovisnN.
<br />WARNTN(i: Faihrc ro $.u6 wo*cK .omp.trsr.on .ovc.r!. is unl.atul. rnd shrll subjccr nn carployer t, o'ninal Ftulrics rtrd
<br />.rvi turc\ trt, h o0c hD dlc{l rhousrfd olltus (SI h.ddiri(r ro rhc cosr olcomncnslrion- da'nrx$ rs phvidcd l.r lh.
<br />S..riotr :107r ol rhr liln Cndc. crci S1/ u7r-t u!-.v 6l-.J v Y1 \-'\;&
<br />I h.rchy irlnm undcr rcnrlryof pcrjury rhar am li(naal unJcr provision ofChaprd 9 (.Dmrmmill! wirh Scction ?000)oll)nisi,{.1
<br />ol lhc Busincsand PNlcssionsCodc. and myli.cns n ir tull lorcc {ncftccr
<br />I-icctr\cclx\\ (i e .17>? sG
<br />Vi v. r-'.-:\s Qi,
<br />I h.Eby ar6rn und.r Fn yorp.rjury rhar r
<br />(sucd lSN.3097. Civ. C.).
<br />rucri)n lcndir8iScncy l lhc Elinirun.c olrhc*ork f(r{hrhrlns 0cnr[ $
<br />AISTICANLDECI,AEAIION
<br />I hcr.bynlIr undci pcnrhy orpcrjuryonc ollhc followinS drl,roliotrs:
<br />Dc'rolirio. Perhis Ashcios Norillcarn,n Fcd(al RcEulnrion\ (Tirlc 40. Pln6)
<br />_R.nnncd L:uc. ol Ndrirf,arion
<br />rcgularions Egudi.E asbcsros e,rcval arc nol q'pli.$lc h ihk prcjer
<br />'.rd rhi\ xttli.xrnni J nJrr rhx( rhd rl\rc inlnnnlnr tr(onc.r Irs'cch.o t'lyrvirh{ll(iryxntl(inn,
<br />!rw\ rcldi't k, huikli'rg coinndii,,. ud h.rchyrurlrri- rcl,.utrrivcr oithn Ciy !trd Counrrb cnrcr trF'n rlt
<br />Dcdy lff inspccrion purpori(.-^"a\,*. 9,/ (r / r0
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsu lation
<br />Roof Sheathi ng
<br />Shear Wall
<br />Framing
<br />lnsu lation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />D eputy Final Beport
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL rplulN 1l tx\^dl ,?)
<br />Certificate ol Occu n
<br />Notes, Remarks, Etc
<br />Set Backs
<br />Ia-
<br />o","'\/l\ / t B
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