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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE IDiSIG.COMMENTS OWNER BUIT,DER DdLCARA'I'ION
<br />I hcrcby offiror undcr pcnally of pcrjory rh,r Im.x.nu rro rhc Co rucron l-iccn\c Ltrw nrrhc followi,s tcosn (scc70.115
<br />,llxiness and Prctc$ioi Colc) Any Cily or Connry which lcquncs ! Ifd n) .onsrrud, rllct. inlrovc, dcB,lirh or rcF dy
<br />itu.ru6, prk,r b ns i$urncc, llr .cquncs rnc anpltznl r{tr \uch tcrnir ro tilc 0 siBncd shremnr rha! lt or shc i\ licen{d pursuanl
<br />ro rhc pn,vnbns orrlr Co.rdchcs Lic.trscd tjw (Ch.!rq 9. Comrmncins *irh sc.rion 7{xlo of OiYnn,n:l of rhc ausincs and
<br />Pft,r.si,ns Codc)ortblr hcorshc k cxcnrpr rhcrctiohud rhe Msi\ r.rrhcallc8cdcxcmflion AnyvnntrionofsslionTO.ll5byony
<br />rtplicant loraNmrit subjccrslhc applicdr ro r.ivilpcndhyolnor nmrcdm 6vc huidr.d dollnE ($sm).
<br />AlA,,*F"rrhcntuEnr,ormycmnl,,rec\trilhsaEc\!slhct$lccoU.ns.lion.willdorhe erknndlh€qmNEkmr
<br />'i rc,x]cd or oficEd ror r'lc (Scc 7(},14. Bu\inc* r.J Pn,lc\rn,nr Codc l'hc Conlrrcrois Liccn* tr* docs not applyh !i own r or
<br />rhc rDpcny wlm bilds or n\rcrc\ irEmn. ood who drcs sEh N|t hinsc lr or hcrslr dr rhmugh hn or her o{n c'n lo)es.
<br />providcd rhlr $ch i.nlmwmrc m nor inrcidcn oficft{ for qlc.ll tx)tqcrlhc ttrillina o, io{,ntftd is stl wihinorc )ra
<br />.f..ntLrion,rh.OwtrcrBuiklcrrillh{rcrhct! cn otPmeing rMr hd or shc did nor build or imProk thc loFdy fot rhc pupas ot
<br />l. rso$n.r ol'ihc pr.|rny. rtrrcttu\iv.ly.orr tn! Nirlr liccnt-d coftrcr{,
<br />n't th,fcsmnCodc: Thc Conra.ror'\ l-iccn\c l-rw doc\ noi.prl, kr M uwtrcr
<br />nnrtc.r (stc ?()1-1. llu\trcss
<br />{ho btrild\or nnftr,r.\ rh.r.on
<br />rn \ho .otrrrurr\n,\u.hfr,lcc r\ \nh r(i{ r.r,tr1r lr.n.(lfr,{'r r
<br />/,
<br />-l
<br />arcx.nrpr uodcr sc.t-e/,2/,8
<br />""".",
<br />I hcrchyxltt ,undcr nrkt.flicijuryon. ofrhc t)lbwirg Jcclrrrin)is
<br />-l
<br />h0vc !tu will nuinrlio a Cenifi.arc ol conscm o sc,f lrsur. tu w.!ke6 to rFnsarion..s rovideJ lor b, sc.rio.]7uj ol'lhc
<br />bhor Codc. for lhc I'c oflmnce o{ rhc work tr which rtE Frmir iq issucd
<br />lh.vc lnd willmrinrain sorkcri comNnsrtnr nsufuncc..\ rcqrirrd htsc.hon:r7(nofrhc tihor G)dc. rd rhc N orunccol
<br />lhc work li,'whi.hthis pchrir is isucd Mysorkcs conrDcnerion in\uruicc.nftu d p.licy trumhcr arc
<br />xprrcs: _
<br />nily rhnr ir rhc t^-rloflnricc ol rlt a.rk tur which rIis pcflnir i\ i\su.d. I sh ll tror rnrt)y |,.^on i', rny .r
<br />I h.co'ft \uhr.r ro thc wo.*cn compcnsrrin ln*s ofCrlifonri{ md iB
<br />Forkn( .ompcnsrt'trprovisioNof sccrion:l70oofrh.Lhtrc.dc.l shrll. i)nhw
<br />$ARNIN{; lir lurc k, \cru'r Nuk(r! (trnD.trsnro r ..!dr.. is trnlrwl l trrl I on cninloyrr t, d iirrl Ntrillic\ nl
<br />civil incs up ro onc huidrcd rhousrnd dollaB l$l(xj.ujo). in uddnio
<br />,_4,4L
<br />Ihcrcbyafiirnru.rFnolryo,pcrrnryrhnrIt li.{nkd uMcr Pmvhion ofcnrprc! 9 (commNirS with Secrbn 7U[).rDivtion:1
<br />.f lhc Busitu{sa.d Por.ssions Code. and myliccnsc h in tull rorcc,xl clGcl
<br />coNsrllllc'l IuN I lrNnIN(; a(;tNcY
<br />I hcrhy allir unddFtrallyolp.rjuryrhirh.r.istr.un(rudio.hndi.8a3.ncyLrrh.FJtun:un.coflhc$.rlfor{hichrhhlcnniris
<br />is{r iSd .l0r)7.Civ. C )
<br />R.quircd Lcn.r.lNorilj.Jhn
<br />_l.cdily ihar rhd ra{cralicgulotions rcgddin8 o\henos lcrfr,vd
<br />mx,.rl,rr I1r\.r.n{lIh Ir|)l)lic rii]trJnt{n! rhrrI ion ncorar I gft b.unrtly*ilh rllCiryaid C.utrry
<br />n srnrrl-rs\ rcldirs Io bnildi.s..n(n,cri rcDrcr arivc\of rhNCirya Counlyrocnrd
<br />nhovc nrnriotrcd prcp.ny r{n i"\pccrion putisc!&
<br />tv
<br />\D0ln'rnl or,\srnr Sismlufr
<br />t',"r,i,. .-,.,t,.ir,,D(-
<br />Set Backs
<br />Ereclion Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsu lation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsu latio n/E ne rqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lr/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Beport
<br />FINAL q //o/H #('/h ?xtuu6-Y.,.nr"a
<br />Certilicate ol Occupancy t-/
<br />Notes, Remarks, Etc
<br />Forms/Steel/Holdowns
<br />Flood Zone Certif .
<br />tJftl.i\ AdJrcs{
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<br />APPI I('ANT DtrCLAI{A IoN
<br />llultr idn undcr |ttrlllv .l pc.iury .m olitu folbsi',! dc.hnriur
<br />Dc'nolirbn l'rnnir\ Ash.n.s Nolilicrlion lcdcrlRcIUbri,tr (-lirlc,l0. Pin6)
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