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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS
<br />Forms/Sleel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Sublloor/Vent/lnsulation
<br />Rool Sheathino
<br />Shear Wall
<br />Framing
<br />lnsu lation/ Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lvlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil
<br />FINAL tvfl/rn (6.9
<br />Certif icate ot Occu nc
<br />Notes, Remarks, Etc
<br />OWNER BUILOER DI'I,CARATION
<br />I hc,cby rliirm un'tcr ncnalry ol ri.rjury rhrr I m.rcmtr linm rhr cnnt,crx! L,ccnsc ljw n, rhc t,llowllre rc6on (Se.roll.s
<br />Busncss iri Pnncsron Cdcf Any Ciry or (iunry whi(h equrcs a pcmil (' uonntu.r. rhc.. iman,k. J.nol$h or rtltfuny
<br />ntu(hrc. nrxtrr, n\ xsuatu.. alv, rqutr r rh. amliunr tnr ruch Frnur i) lik. rSncd sucmtrr thrr lEor shc n l'.cn!.{ pusun(
<br />to rh. pnlvNi)ns o, d. C,r racn{-s Lkcn$d La* (Chrprcr q, Commr-.ng * h Sc.rn,n 7UU ol D,vron I .trhc Alu.ss atul
<br />Pinc$n)ns Co,lc) or rh{l hc or shc i\ c\.mfl rhercril,mrn'l rhc hasis ntrrhc Jl.gcd.kmtinrn. Any violationofSe_rion 70.11.5 hyany
<br />lmh.anlturapcm subje..lsth..pph.arlloa.irilp.nalryofnord,crhanlivchundr.ddollirs($5lJo).
<br />_1, u owftr of rh. l,opcny. o, my .mpl,Dyrs w I w.8cs .r rkt slc (onrpcns ion. will do rhc wotk arrl rh. sMrur. 6 nor
<br />mrc,ri.{ or ofljr.d tr $lc I S...?(X4, Au$ft$ .tu1 I'rdtssons Cul. The Conra&tr s l-t.n{ lre drts hor af'lly h .tr owk! rf
<br />ih. ln)Fny wN' htrilJs or iqr,,!cs rh.rd ,lrtl *h) d$ ruch w)d( hrm\.llor hcrcllor rhr'!3h his or hs own cnpkJyccs.
<br />px,v!.lcJ rh $.h mpro{mnk rc nn ink,rlc'l n oicrcJ ,tr sL If. h)wc(r. rlf, hriuir8 or impotrnr r $U vnhm onc }tr
<br />ol.1,n\rLrr)ll. rh.O*.cr Au,L].r w,ll hrvc lhc htrdcn of pfl)vuB th.l h. or shc Jil nn htr'U or idlr.vc Lh. Jln)llny ntr lh. Pu4Ds oi
<br />_1. rsowmrol rh. I,n,p.ny. dmcr(luivclyronlradm! with liucn$! conr! ltrs b (unrud rhc rlEd (S.c 7044, Buv..s
<br />r hoicss$n Codcr Thc Conlro.ktr's L(cnsc L.w docs Brlalnl, t) an owncr ofnn'p.dyeho brilds o. rq)rovcs rhcrc.n.
<br />an! vl$ conrrauh lbr su.h IroFk *irh a Grnka(bd s) lrcn*d N trdr b rhc Contro(nn s l-icnse lj*l
<br />-l
<br />lmcicmfl undcr Sc(ton-, B & PC turrtus rc.son
<br />.IYOATEEI].IjOIIIENSAIIAN
<br />DECLASAIIOX
<br />I h.r.by rltununJcr l.nrlry or tdjury onc otlhc li)llo,ine dcclnorions:
<br />_l hrvc rrl will minrrr r C.nili.{c of Conscnt b Sclllnsurc lir *.rkcs coryf,Narion, as I,l)viJ.J ro. by SR-ton l70O of rh.
<br />llh, CL{c. Ior thc lEriormfrc Dl Ih. $lt n, whrh lh€ pcrmrr n rsuc.l
<br />I harc ind will mornuin workcri comocnsat,on insusn.c. rs rc,txiftJ hyS.cnon lTUlofrhc tjhor Codc, thr lhc Pcdnrmnuc ol
<br />th. uo ntrwhirh(hn pemir is n\Ed. My*nrkc.s cory.nsar n i.strdtrcc (ds {rl Blli y numhcr !r.:
<br />t-r11a
<br />l0h/>!)a
<br />I L.nity lhd in rhc p.dnrroNcollhc w r[ ltr vhichrhtr Frmir i\ asu.d.l \h,llnor crPloyany!.rs ranym ncr
<br />n, r\n, bc$ft suhj.rrbrhtwork. ronFn\ruon laws ofcll'n)nn.. ,3rcc rhrl ifl d[ulJ h..om sohFli brh.
<br />workrrs comrns,rnr pro!,lons .r Sc.rn)n 17m ol rhc L.htr O{c, I rhall. ,nnheirh omply pnh rh,r ln)vrn,ns.
<br />IVARNINC: Fa'lur. r, *'.r. w rkcd eon!.nsrhotr d,vctutc r\ unllwtu], {nJ shru rubFr an .mpl,)fr b 6mil lEn.k.\ and
<br />civn lincs np t(, orc hu rcJ lhousrn,l d.llus ($100,&0
<br />Scsrioh 10?6 or'hc bhtr Cqlc, intcr.{ rn,l lrknEy s ier.
<br />I hcaby afiirh utulf Fn,hy or F*rjury rha' I am liL.n*l ud.r I't)vEil)n ulCMfls 9 (commBin3 *ilhSe(lion ruo) olDivnn,n l
<br />ol rhc Busin.$ and Pnncssons Cod., rnl mylir.nsc ( inhru tue!! clltcl.
<br />.*,, k
<br />I )J > r/ >,tn.0 conimro.
<br />,T"M
<br />-z;;=7( (lNsrRucrtF t,tr6[Nc ,\cENCY
<br />I h.L-hy,lltn, un'lcr Ftrxlryol F_qury rDr rhc'r L n coinru(ron LrklnE ra.ncy itr rhc lcni,rmrnrc ol rhc sork i,tr *h,!h rhls Frnnt L
<br />nsuc,l (Se 1097. Civ C.)
<br />API'LICANT DDCLAIL{TION
<br />I IEELy rllim utrJ.r Fn,hy ol r.riury om ol rhc tulhwmg J.Llddi('nr
<br />Dc mln nm P.rhrtsAsh.(or N iiir..lbn t cderal Rc8uhr$ns fl irlc 4(r, Pan6)
<br />Rcqnnc,l Irlrcr ol Mi'll.!riu,
<br />_l c.nili rhar rhc l.Jc lrcAulariux ftlrd'ng.\b.ios rm.vrl.r. nn dtpl'cihlc b rhN pn+ur
<br />-L& rcnilyrhd Ihavciudrh'rar car ndl narc rl'rr rhcrtr,vc I .tra lo ronrply wrrh dlCiry rn,l Coun'y
<br />onlo,nr.c\.trr1Srr.l.'w.r!'Lrr'03 k) htr'lJ U (on{ntrr n.y 'xrhfz. rqr.$nrr,vcs orthis Cny M,l Counrylo cntcr uFJn tlE
<br />{$vc mnli(nFJ pr)p(dy li)r i.sFoii{,
<br />y'Applicmt
<br />or Asetrl sisrolure
<br />) tcmrlte mnerp;nO
<br />l/2oza
<br />f/7,o.7t
<br />Set Backs
<br />UFER Ground
<br />"",, t )./ >-Y z i' Z0
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