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BUILDING- INSPECTOR RECORD
<br />ID/SIG.COMMENTSSITE.WORK DATE
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />))Sublloor/Vent/l nsulation
<br />Roof Sheathinq /D.l,z-fr C?,'?-l 7/
<br />Shear Wall
<br />Framinq
<br />lnsu lation/Eneroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lt/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />/U/z/td t)
<br />Certif icate of Occupancy - / (./
<br />Notes, Remarks, Etc. t
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<br />OWNDR IIU!LDDII DELCARATION
<br />I ricrchy trlrir undd Fnolry ol periury rhar I 4 cxcmrr rio (hc cotrrldo'r l-i.tns. u* r.r rhc lnllosins rca-- 's""orr 5
<br />Busnr$ r Prolc$ion adc) Any Cny or Cotrnr, w|i.h rcqlne\ r Irmir tu .on(n'd. ahcr' iqi.v.. dcnnlish or rcpan anv
<br />nrucl[c, friorro irs i\suan.c,dlsor.quircslhcuDDlicitrlri"{uchFnntoiilc,\i3.cdslltcnEtrrrh,th.orshcisllccn*dPo^utri'
<br />t' rhc pmvnnnN of lhc Conlr{.lo s l-icc0\cd l-aw (Chrprcr 9. c-onnncncing *irh sc.rnJn 70u} ol Dirnion 3 of rh. ancin.s( ,nd
<br />l'iolissiotrsCodc) rlhrrl{or.hcncxcu rhcrclinn0 lhc hosk Ltrrht dlcgcd . rc n{'l ion Anyvdsri( olScclionT0.ll5hvany
<br />apDlicxnr for rtcfln suhjeN lhc uptlicatrrro acivilpcmlryolk, ni)rcrh ivcl ndrod dollrrs ($5(x))
<br />l. rs oqncr o{ rhc nmrcny, or my cnployccs *nh wrscs ns lhci q,lc oml).nsar ion. will do lhe sok $d Ih. $udE ir rn
<br />inrcndcd or oilcrcd for qlc (s(.7(x4, susirE$ otrd Polcssions C,rlc Th. G,nlroclois l-iccnk tf,w dN\ nol .t'Plv lo a. owftr or
<br />rhc pml.ny qho tDilds or ir{,mki rhcmr. dd who d€\ {u.h *!rt hi'nsclfor h*selfor rhnruSh hh or h.r own cmPlo}tcl
<br />pmlid.d rhri such impmvcunt m mr idcnd.{ d oftdti tor $L lt ho*cw, rhc hiklirg or it!)row'Enr is vrld wirhin .m ]c-
<br />of co.Dhrion. rh. own r Builds uill h(rc lh. l'arnc. oI F,ving rh,r rf, or shc did mr huild or inpovc 0E ,,Dpcny r.r rhc t qn$ ol
<br />-1.
<br />us owoer ot rhc prolrdy, am crclusiN ly .ontrrr ins wirh lidnsd conr,i.ro6 (' constu.r rh. ,$iN (Ss 704t 8 (i".*
<br />rkl Pbfcsim Codc TncCo d.ttr s Li.cnsc Lrrdocs norrpPlyro nnosn.rorlmncrlysho toild{ornnfrorcs rhercon
<br />rnd who.onlrmclorsuchproj(kwnb,conh.r)dnli.ctr*dt]usumrhrhccont,.tn\t.i.entljw)
<br />I n.r.nhr utr.l.r Sccrio
<br />Drr.: O*rer
<br />rronxrns' cotnt ws,rrrox
<br />DIgI.AIAIAN
<br />I hcrby rrfirfln.dc. pcnally ot pcrjlry un. ur'lt rolkrsinS dccln.lions:
<br />-l
<br />hrvc ul will roinrain r Ccd,ficorc of Conscd n, Scla ln\rrc ror wortcr' ompcnsarion. as provid.{ fo. bv Sedin .r70o or rhc
<br />hborCodc. nxlncpc.,o!@nft of ihcwork lor shichtne ncrnri i\ nru.d.
<br />Ihattrndwill.ri'nxinwo.kcFconrNn\ari{ntinun'mc.a\rcqur.dbyScclionl7(()olrhttjhotCodc.lorrhcpdfonru.ccof
<br />rhc sork lor *hich lhtpcrmir il i\\uL{. Myworkcis conrp(trsrri{nt su6ncc canicr et rri.y nu'nrrr dc:
<br />(!ri.r
<br />I.cni,y thrr ir rhc rcri.nDncc olrhc solk tu which lhis Pcn.ir i\ i\sucd. I shtll nor cnrloy rny p.r{r irr rtrv nxmrcr
<br />e !sio tEo'E subrccr b rhc soikcN comPcn\nrnnr hvs ofCnlibrrir. rnd !3rcc rhrr if, shruld bcc.m subicd r. rhc
<br />*rrkcli comlltisrrn,n pn)vnions ol S.ct i.n :17(X) ol rhc Lhtr Gtlc. I shill. lirdhsirh .oNPl, wirh th)e Poli\nff.
<br />WARNING: Frilurc x' {.trc workcn .onrE,\.riotr covcsgc i\ unllwrul, Md rhlll suhjecl m.dlloitr ro siminal0ctuhi\ and
<br />r) rN huRlrrd rhou\itrd (loll.trs {tl(xr.lxxr). i', rJdirIn ki rh. co{ o, .onrcn\nridr. drtrug.s trs Pn,!idod lur rhc
<br />sc.ri(rr.1076.1 rhu l.rhtr(itrl.. iN.rc\l dtr(l ntr
<br />DECLAX{IIOX
<br />undoprovisi( rofCh prcr9(.o'nntrcinsqirhSc.ri(,n71tr0)olDivnion:lI turcl,yrrlnrutr .rl[ rlr,o1 ]rcrjuryr
<br />oi rhc llD!irrs rnd l'fl,rcsnrrN C.dc. nid nry li..D{ i\
<br />Et cg 9// 72 7s
<br />"",", 9-/z-,/8
<br />I hcrchy linirn ud.r !.nrxy oi t'c,jury I har I
<br />hsrcd (Scc :10e7- Civ C)
<br />i( lcndir!n8cn.y larrhclcrlnrnun.c olihc {ork forwhich rhi\pcrn,i! i\
<br />knJcrr Na'rc:
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<br />-lccnilrrharrhcf.dcralrcgublionsrcSudinBs\bcdo\rc
<br />x,vnltc tror uPplicsblc r, rlls Pm.,ccr
<br />Ilkrrion alxl natc lhlt Ihc olFrc infomrion is..r(t. llsG lo.onElywirh trll Cirylnd Counry
<br />buildine .onnruclion- 0{, hcrcby !orhr,. rcrcsnhrivcs otrhis Cny.nd Coury t' cnr$ uBJn rh.
<br />*,"215-12
<br />C4zTezz
<br />Flood Zone Certif .
<br />FINAL f 4{/1
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<br />2- l7-R
<br />APPLICANT NF(:I ARATION
<br />I ho$y lmm under penahy orp.rjury orc ollhc fullo*ins declaturiotrs:
<br />D..dirio6 Pcrmih'Asbcslos Norin art'n FcdcrnlRcgulnrions (Tirlc 40, P,n6)
<br />Rcquned Lcttcr orNoriti.drbn
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