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)BUILDING. INSPECTOR RECORD
<br />SITE.WORK ID/SIG.COMMENTS OWNDI{ BUII-Di]i OI]LCARATION
<br />I hcrchy rlfinn undcr pcnalr, ol f,c.jury rhd I anr cx.nrfr rhnr thc Cotrlroclo\ l-ien$ Ir* r(r rhc rollowin8 rcas,n (Scc 70.ll !
<br />8u\inc$ and Profc\\ion Codc): Any Ciry or Cou y nhi.h rcquires r Frnrir ni .onqd.t. tlrcr. inr[ovc- dcmlish .r ft0rn ndy
<br />dru.rutu. prn b ns issurncc, uho rcquirrsrhc arpli.dnr ntr lurh p.nnirro lilc. siS cd slsremnl rhar hcor\hc ( liccnscd Nrsua
<br />k, rhc ttuvisi(,n\ ofrh. Conmcrols Liccnscd lj{ (Chlllcr r. Co'nm.n.ine wilh Sccrirr 7UD of Divisi(i!:l .l rhc Busincss rtrd
<br />Pn,lc$iotrsCodc)orthrl hcorshc iserc'nfl rhcrc,io mdrhcMsi\rurrhc lc8cdexcmplion Any!n dionolScdiotrToll.5byarJ
<br />nnnlicanr t(aFrmir !ul,j(r\ rhc anpli..nr ro i.ivillcMlry.l mr nnrc rh fiv. huRncd dollais(i500)
<br />I. as owncr ol thc |,oltny, or nry cniPk,]er {irh wrScs 8 thcir slc comPctrsorion. *ill do rhc woik bd rhc smrr is ml
<br />iNcrvlcd or.ficred for slh (Sr 7o4.il. Busincss Nnd Pr.lcssions Cor]cr'IlE Contlcttr\ Li&n* tia docs not lprly lo m owmr ol
<br />rhc nmrMy wh. tnrlds or in{,Drcs ihcrcD. Md wtr dB sach tu* himsclfor hcr*ll'or rhn,ugh hir or hfnwtr carPloyccs.
<br />rovidcd rhar such nnfr(^rhEnh e ml irtcrhd or oltbql t, ulc ll. lb*tkr. rlrc hildin8 or imPFrcrm is b Rnhirr.'nc)td
<br />ol conq'hri'n. rlL Owncr Buiud will h.w rh. bord.tr .f JrovinB rhal lE or shc dil fr, buikl or inPmh rhc pmPcny fo, lh. puq.*_ ot
<br />l. * o*mr of rhc J)n'p.ny. amcxchsnclycotrrr.ctins *irh liccnscd cont ktrt r, lrtr{ru.t lhc pn,rcct (Sc. ?0r4. Busm:r
<br />and hDfcssion Codc lhcConrrs.tn s Li.cn\d Ld* do.s nor ,mly h nn o{ns ol PrcP.nr *h. bu'ldsor i.nPmvcs rhcr.oi.
<br />!trd who conh.a ror su.h ptuF:ts Biln a Coftrdo(n liccDsrd pu*u,trr kJrhcContrrcrols Liccnscl2w)
<br />D.l€: Okn.r:
<br />}TOTf,EIIIij:AUIINSAI]O!
<br />D[glnLBAIlON
<br />I hcrcby afilnhdcr pc.dlry dl ti.rjurt onc oirhc iollotring dahrolions:
<br />-t
<br />havc lln will moinrain a Ccnificrrc or conscnr ro sclf.lnsurc for worlrcr' conrtBsrn,n. as fmvidcd for by Sdbn l7m or rh.
<br />ljhor Codc- lbrlhc Dcdormanccdf lhc wort for whichrhc p.iinir i{ isrucd.
<br />lhr\crnd$i11'nninrlnsork.r\.conlrn\{rnlrin{mn.c..\rcqtrir.dhtSccri,.lrU)oirhcLrtxrCodc.larrhcr^-rfonnrr..l
<br />rhr work ntr whi.hrln !$mn iis cd My workcr' Brmnctrsarn,n in{mnccc,nicr Mllnili.ynunnE!ru
<br />l.cnif! rhd( iD rhc |xiforrun.c oirhc wo'k li,r whkh rhir Firnir R rsucd. I \h,ll nor cmPk,y rn) P.rn ir.ny nrtrNr
<br />$u\hbcco'tu\ubjccrbrhcwo*c6'c.rnrnsolionllsrolCslifon,i!,andasto.rh il I should t'cuN hj(rt,rhc
<br />$oAc( c.nlcnern pmvisions ot Sdion :17(D ol rh. l nhr Codc. l \hall. tunlrwirh coflrDly wirh rlm$ tfl,visions
<br />WARNINC: l:ailurc b ecurc sorros .ofrncnsdn)n.ov.r,!c is u.hwlul. rtrd \hall \!hjc.i r'1c'nPlolcr lo oirrird n ultic\ and
<br />civil lincs ut to onc hundrcd rhousand dollnrs tsllD,fftr), ir.ddili(r ro lhc co{ ol$iP.nsdtrin. danrBcs as Pmvidcd fttr rh.
<br />S..rio. :1076 ofrhc LjtDr Codc. inleEd,nd rtromy \ rccs
<br />Dr!.: Applionll
<br />, ,cunsrn con:rntcron _
<br />DECIAEAIITIN
<br />I hcrchyaifirm unds r.naI, ofFrrury rhd I.m li..na{ u ct Eovhion oa Ch{rer 9 (c.mmncin8 wilh Sal ion 7O@) or Division J
<br />of rhc Busnrsa.d Prctc s ions Codc. lnd nrylic.n{ is in lull ror.c md cficct
<br />CON BJJgIIAIIENDINGIjiENII
<br />I hcmby aflir u.d.r,r.naltyofFrjuryrhlrrhmh!c.nsrrudbokndnrgagcn.ylorrlNrcrlornunt.orrh.worklorBhi.hrhi(Iicmrilis
<br />nsucd (Scc 109?, Civ. C )
<br />APDI (- NTNT(]I ARATIoN
<br />I llni6!am und.r Fnalrt ofp.rju,y om {llh. n'lk,wing dcclarariiJns
<br />Dcnt,hion Pc.ins Artrsros Norifi.arion F'cdcr0l Rcsuhrn,n\ ('ribr0. Pd6)
<br />-Rcquncd
<br />lrucrof Mnifi carion
<br />l.cnilyrhdrh.ltdcrolrcsulolionsrcCardinga\tno\rcnx,!al rd tror iPflicihle lo lhi\ PmFt
<br />I ccniiyrh0t I havc rcld rhi\applirari.n rid s,rcrhmrhc rbvc inlnnrution ncomd I nsrd r. compl, $ilh (llCilyrndCoudry
<br />ordinrmcs atrd Storc ljws rlarin-s t, huildi4 con{o.riun. dd ,rrby durhoriz. lcrctnrsriv.\ ofrhir Ciry lnd Counly ro cnr.r uFnr rhc
<br />$orc ,tu rn,md,tup.ny for inspcd ion purr,rcs
<br />(t't)lnxtrr or \!ul Siln lurr
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsulation
<br />Roof Sheathino
<br />Shear Wall
<br />Framinq
<br />lns u lation/E n erg y
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />l\/ aso n ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req Ul ln /-12/{t,
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL uTlto)l,u/ul 1)
<br />Certiticate of Occupancy
<br />Notes, Remarks, Etc.
<br />DATE
<br />Ltrcn\c Nun'tr' -
<br />lridr''( 4Jdrs _
<br />Flood Zone Certif .
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