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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsu lation
<br />Roof Sheathin s
<br />Shear Wall
<br />Framing /0 - l0*/r X-\L{.10
<br />lnsu lation/Energy >3
<br />Drywall /o-(t-lY \'.w3t)
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />ncCertificate of Occu
<br />OWNER BU!LDT]R DNI,CARATION
<br />I hochy afnfln undcr linrlr, of pcrjory rh,r I an.rcopr lrod rh. Conr,.hn Liccnsc hw lor rhc lbllowi.E r.!n,n (s..?oll5
<br />Buiincss Md Prorcssion Codc)r Atry Ciry or Cou ry which rcquncs d tc.nrit lo mn(rud. allcr. inltlnrr. d.mlish or rcpri any
<br />slrucluc- nritr ro ns issuancc. .lso rcquncs lnc anplicitrl lbr uch pcrnrir lo 6k r \iEncd flr.nrd rhrr h.or shc is liccnsed Dusun..
<br />to lhc phvisiotrs or'h. Contrrctor's Lic.trscd tj* (Chrprcr 9. Comnrcncins sirh Seclion ?Oo0 6f Dilisnrn I orrhc Bunn.ls and
<br />Pnfc$hns Codc, or th.r h.orslrc kcxcmfl thcrclrom ond thcMsis tor rhc allcsed cxcmprnin. Any vn,larionotsstion?0315 hy.ny
<br />rytlicont lbra pcrnir suhjects lhe omlica ro acivill]cn!hlotnot more rhan lve hundr.dddll& ($51D).
<br />-1.
<br />6 osner ol rhc ltrorsnr- (, ny cnployes wir h $rsc\ as rhcn vn. cotrP.n\diotr. will do ltu wort and lhc (nrl@ i( tror
<br />i ..nc{l or dlTcrd foi srlc (Se.7O44. Busincs and Prorc$idN Codq Thc O,nrradff \ l-iensc llw d..s n.r aml, to tn ownq of
<br />rhc pmld, who huilds or nnf,rcws rh.a)n. turl wth dB snch wrk hi.Fcllor hcrell.r thmoCh his or h.r own.n[loyccs.
<br />prortlcd rtxr sDch inll)mwmoh ac nor inrcnded or otltrcd lq ek ll l$w.vcr. rhc buikliu or inlpolcrrcnl h $ld *irhin .nc ]ur
<br />oi.onpLtir. rh. owncr auil(rLi will hrvc lhc hrrdcn oil,ovin8 lh,t hc or shc Jil ml bild or in{,ov hc p$Fny for
<br />'hc
<br />I4trFJt.f
<br />I.i\owNr.,rhcrop.ny,rucxcnxivclycontrNnrs$irhli.cn{d..nrx.!r^'o.ondturrrhctbid(sc.7l!-1.|,u\ncs\
<br />x h.Ft\i)nCoJclhcCoikr.rtrsLicciscLrwdocsrorlrplyrortrow.doltn)|criyNhohuildsornnprovcsrltfco.
<br />rnd *ho conr0.k foi such lrojcd\siih. ('onrndo( \ r li.cnsd purunr hrhcConkrtr\ Li.cnsc Li!).
<br />-l
<br />umexcnpr undcr Scclior-, B. & PC rd rhh r.dson
<br />Datc Omer
<br />lyABA!f,LljAM[EN$IIAN
<br />DEUAAA]ION
<br />I hcrchy allirn und.r p.nrlryol pcrjury o'm of rhc lhllowi'B c.lmrions
<br />_l havc Md will nuinrai'i a C.niarnr. or C.n{.nr ro sclr l nsurc for sorksl comFns ion. $ Imvidcd ior bySdion:1700 or'hc
<br />L.bor Codc. tbr lhe lcnnirurcc ollhc No lor which rhc p.n.il h hsucd
<br />_l hrE url willuu,inrriD \o!kc^ onilj.n\ari,'n i'r\urJtur, J\ rrqutcd bySr.ri l?00 .1 rh. lr6or Codc. itr rhc p.rformance or
<br />rhc *ork torehich rhhlrLrnrir is irsucd Myworken compcr\lri.in i'rsuRn.r.nrid dxl lolicy numb.r .rc:
<br />l\,liry NtrD,nrr
<br />-Exf
<br />tr.s
<br />I .cnrly rlrar in rh. ltrloinun.c,,ilhc sork br rhich rhi! t iinir is i\sDc.l. I shxll tror cmdo) r',t nLr{,n in rn, fh.trcr
<br />$ rs b bccomc su$jdd n, rhc trorkdi c.nrpcns lio,laws orCrlir{riir. rtrd rgnc rhrr ill tlnruld lr.nrc nrhlNl n) rlr
<br />$ork.r\ conrl,cNr(n)n pmvisn, ofSc.rion:17( otrhc t.rhtr Codc.I \hrll. tu(h\rith ..nrdy \ ilh rnor prni\i(n,!
<br />WARNIN(;: F lurc kJ \ccurc workcr .ompctrs.ri eovcri8c i\ uf[$hl. rntl sh]ll {rhF.r , cndoycr ro.'i,nirl l)cntltt! J
<br />(ivil nNs up tr' onc hunJrcd thousrd dollrs 10o.fi[])- in addnion ro rhc co\r of.otrlJrneri.i. drmScs trs proridcd for rhc
<br />,Sq m l<"
<br />L2r!! -8t!I,}1!hcrbyrfinnddd.rFnikyofp.rjrryrhdIrrli.cn$du,l.'prclisi.trofChipr$9(connmncirgkirhSccrion7000)ofDivisn l
<br />ol rhc Busimsrud Pmra$ionsCodc. od nr) lEcnsc n in tullforcc ud clrc.r
<br />B c-7 q fPTv b?
<br />*,. e01r+/t{lrtav O^r,tr*trtu, I hz_
<br />I hcrcbra,ftnrundcr p.nrllyoipcrjuryl
<br />issucd(ss ltr97,civ. c )
<br />consrru.rin Lndirx rAcmy lnrrltn rtunJunc. ofrlt *ork Ior \hi.hrhhFmril is
<br />AII]TCANLDECI.A.BAUqX
<br />I tmh, aninn undcr r.nally olpc,jury onc olrhc followins dal&lionsl
<br />Dcm)lxion PciinirrAsb.ios Norific.rion Fcncial Rc8ul.rions (Tirlc 40, Pan6)
<br />Rcquimd ktr$ of Notilicdrio.
<br />-lc.nllyrhrrrhclidenlrcgulari{,Nro!
<br />li'rg r\If,(o\ rrnntrrlr.c norrptiii.rhlc tJ rltir fbj..r
<br />n n a,rl *dc
<br />'hJt
<br />rh. Jh,vc ir,onMriur is.oral.IrE e tocomr
<br />buildiu con{rucrion. .nd hcrcbt iuihorizc rcprcsctrllrivcs olthir Ci
<br />""-,,*,"-sf San- En
<br />,€/tE hr
<br />ID/SIG.COMMENTS
<br />Forms/Steeli Holdowns
<br />T-Bar
<br />Flood Zone Certil.
<br />FINAL
<br />Notes, Remarks, Etc.z:..0
<br />t--+--
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