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BUILDING. INSPECTOR RECORD
<br />SITE.WORK DATE IDiSIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenUlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsu lation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />lvlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL tol{lN'i nl/fiw4t4 7s.D-/
<br />Certilicate of Occu n
<br />Notes, Remarks, Etc
<br />OWNER AUILDER DELCARA'I'ION
<br />I hcrchy rrlnnr undcr rnrlly oflcrjurylhtrr I fln cxempr fnrn lhc Conrrrl{r l-iccnsc l-a* lor rhc f{,ilowi're r.ae,n lsc.70315
<br />Btr\incs a'rl Pn,f.sri,,n Codc) Any Ciry or Counry *hich r.qunr\ r lrrmir t, d iru.r. nlr$. nnPn,vc. dcrmli\h i rcIfun ,y
<br />nrudua. pidb nr nsurtre, nlso rcquncs thc ippli.nd tursu.h lElnit ro flcr si8tlai srnrcrmnr rhll hcor dr is licciscd ftrur0r
<br />h rhc pn,vist,ns olrtE Contacttr \ I-i.cn{d ldw lClEpicr 9. Connfttui'r8 wirh sccri.tr 7ux) oi Divnion .] olrhc Rusincs rnd
<br />Pnncssior\Cod.)orlhtrr h.or shc iscxctrrpl rhcrel'rorrni rhc bNk lorlhc 0llcg.d c{emlrion Anyridarn,nofSccrionT{r:ll.5hyai)
<br />rntlicinr ior n p.rnrit subl(tslhc rytlicanrlo.civiltcnalryofnornnrcrhanfivdhundr.ddolhrs($5m)
<br />I. r\ osncrolihe lx,IEny. or i, cnfloyccs wirh s Bc\ rhcns,hcotrlrn\rrion. willdorlEsork adrh! nnduri\ mr
<br />i .frtcd oroflcrctl for salc (Se.?lrl,{. Bu\ircsand Pn,llsions(id. l}c G,nri.Ln \ l-i.ci* lj* .locs nor on/y ro rn owns of
<br />rhcnmltny n'h. hurds or inDrev$ rhcrq,n. d*hodmssuchwo hims.lfo'h$sclforthroulhhirorhdown.mPl,)!cc..
<br />f(Jlidcd rhrr su.h inl(trrfrds m mr i cndLn .r olLrcd Id srlc. l( hourq. rhc htr itling or inrnntrEtri i\ r)ti s hm om )ur
<br />or con{,hn,n. thc Osncr BuildLa willl'rrvc thc bu(hn ol Drcvirs lh h.orshcdilnorhui[ori.qii()v.rhctmFilyfnrlhcrurrxcoi
<br />rnd *lD c.frrd\l.r{Ehtnd..r\$irhrC.nkr.nr(srli.crscdpu.surrrk)rhcCorr.ntr'sl-i.c!.LrN)
<br />-l
<br />atr'cxcnrnr under Secrn
<br />uaBtr!f,li:raulliNs lloN
<br />DECI.I&T.IION
<br />I lr'.hl r ll irD utr,ldr t.mh, of |xrjDrt on. of rhc n,lldv i',! d(hrrrid,\
<br />-lhrvc
<br />and $illnuirrrinu C.flificrrc of(i,rnr t, sclf ln\um tur s.rlcrJ .onDcns.tiur. ns pmvidcd ttr hysc.!i, lTlroolrhc
<br />hhor c-dic. r{trrhc!.rLrm.rcc oirhc work lnr shich rhc !.rnri is n\ucJ
<br />rh. *ork ntr \hich rhl\ t^-.nnir is irstrcd Nlyworkcl. cotrrl)ctr\drr [{tr...c.iiricr Jr] Irni.) nun,hcr ar..
<br />Iccniryrhorirrhcr(rinnEneoilhcworkf +hi.hrhi\I}cnnir i\ i\sucJ. I null tror .trUoy lny Pcron i!oy nBnmr
<br />s, ro h.conc shid h rhrwork$L..rnJf,nsrrir,n hssolCrlltunrii. rtrd r8rc.ihar ill dr)uld hecoru hr.d rorhc
<br />sorltc^'conpctrsari{nrpr'li\ninsorSc.rnr:lT0Oofrl[lrhtrCodc.l\hrll.ionhwirhconr y *irh ino* [ovi\nnrs
<br />WARNINC: lailur. t, {cor workcr\ .un|ti\dn c.r.n!c is unhefnl. atrd shnll sublccl an cnrtnor$ b .n ritul ff,trrhf,\ n d
<br />.ivil li"cs trp t, on.lruddrd rhousrid dollas (Tl{X).UXr, h ddni(r b rhc.o( otcornpcn\liioi. drnrlc\ rs fiovidcd lor rhc
<br />S..rn'i .1076.lrlf trtrtr Cod.. ntrcrci aM fionry\ rN(
<br />l)ore: Applidnr:
<br />r IcENspo colrn,rl:rl|n
<br />IICLASAIION
<br />I hcrcl,yllftD un{llr pcnrlr] orrcrjury rhar I am liccnsd nndcr pn,ri\ion orChrpt$'r (.lnnrcncin8 wirh Sccrion 7Ux)) .1 DivNi'r :l
<br />.t rhc ausinc$ d Pbfcs\ions Codc. and nrylijensc is in tulln]r.c r cfi..r
<br />qANiIIICIIANIINDING-8IiENII
<br />I hcrchy oifilnundcr FmlryofpcrJurt rhar rhcic i! r.oniru.ii,n Lnding r!.ncy tor ihc pcrti,rmrncc ofrhr *o'k for shich rhs lErnrir is
<br />isucd (Sc. l$r7. Civ C ).
<br />AtlUsANLl,UilLAB/[I0N
<br />I ltNby d]ir trnd.r tcnrlly oI Pl.rjurt oi. ot rtu nnb*i',9 dccl rrr(ni\:
<br />Dcikrni(n Pcnn rA\bc{o\ Norilic iotr }tdcralRcEuhrions (1nlc Jo. Pan6)
<br />Rcqui'd Ir crof N.rllcirior
<br />lcrnilrrhd rhrf.drrrlrcguhriois rclorltrU Nhc{os rcrn,vrlrc tror ifpliHl,ic ri ihn pni.Frr
<br />_l.cnilyrhrrIhrv.rcndrhi\atplicnri(r nJ {nrcrhnr rhr rlx)vc n,foirnnrinr i!.otrc.r lrtrNt,conrplywirhrllCirynfdCounry
<br />ordiritr..\ anl si t.l-r"r rclnlirs lding consrrucrion. !d h.rchy!,nhnz. rcfrc{nlnrirc( oirhh ( il} and Coonry k, cmd ulr,n rrt
<br />,,tn)r. nkrii,,r,l !n,p.'r!
<br />At,t'li(c or Arr tSix n V'Y, tY
<br />r33f U 7E/w
<br />I
<br />Erection Pads
<br />trnlci\ Ad(tr\s
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