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BUILDING- INSPECTOR RECORD
<br />SITE.WORK ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />-ytttl-trtRoof Sheathinq gllhlt{,'fz)
<br />Shear Wall r 9,J
<br />Framino
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />l\4ason ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />FINAL
<br />Notes, Remarks, Etc.
<br />OWNDR BU!I-DER DEI,CARATION
<br />I h$.by ,trtrm und6 lxfllhy of |rcrjury rhar I a cxcnll)l from rb. Co tacb^ l-iccnsc faw for rhc follo*iry Eaq,n (S] 70.11.5
<br />3u.nrs ond Proltsion (odc) Any Ciry or Counry $hi.h rcquircs a ,)c nrit lo comlru.l. allq, imlrot. d.ndNh or EFrt rtry
<br />sructurc. prioro irs h\uicc,,h !.qnn.s $. ippli.0nr ror such Fcrmii ro nt a sismd srar.rt.r rhar tror shc i\ licctrtd nurua
<br />b th. Uovti.fs of lhc Co.lriclols Lic€nscd tiw (Charlcr s, Gnnm.n.ing with Sc.ri(r 70(n of Divhi(,n.1 orrhc Bu\in.ss,nd
<br />Pmnssionr Codc) or lhar hcorshc hcrcnfl rheEtromsnd rhc basis ror rhcallc8cJcrcnDlion Anyvhl,rionorsdrionr0ll.5byrny
<br />0pt'lic0nr i.r ep.mirruhjcch rhc dppli.ntrr ro r.ivilr.nalryorrcl nnrclh0n nve huftircd doll,r (S5m).
<br />L N owncr ofrrB 0n)Fny. or mycmplo)ecs sith,u8cs ns rhcn v,h..mrcrs ior. willdo ltE *otk anrl rhc iluluR i\ nor
<br />ir c d oroficrcd lor ek (S( 7044. Busin.s Md Prof.srn Ncodc Th. Conlr..loi \ l.kcn{ tlw drEs nor ipply ro !tr orn tof
<br />rhc pnD.ny qhot ildsor i,i{'ows rtErcn, a.d *ho dms nrh *olk hinNlr or hcrsll or,hmughiis or hcr o*n dnDloyccs.
<br />,i(,!id.d rhd su.h imtmvcmnh N nor inlcdcd or oitr& i, {lc. Il h.scv.r, tla tnnldi4 or i&mvernr i\ sB wirhin .nc ,cd
<br />otconplcrion. rhc Owrcr AuiDcr *illh.rc lhc buftLn of Fmving lh, hc or shc dil tur t ild or nr\.m\t thc pmFny iitr rhc Pdqn$ or
<br />-1.!sowncr.i,hcnmFny,r.r.lusiv.lycotrt.crirrEwilhli.cnscdconlracknshcoiirudrhel)loicl{Scc7(14'1
<br />l]u\incn
<br />,id Pn)LsshnCodc Thc aonnncntr s l-iccn{ 1,trs'doc\ nor applyru aiowmroiPr,),)cnywho buildlor nnfovcs rhcrcon.
<br />rnd \ho conr.acr\ ttr \urh In!..r\sirlrn Co rr.1,trl\)l'.cn\cll0tr'{,.i i n, rl'. (n I'rLr,r'{ l-'.. r\c l.,Nl
<br />-l
<br />!mcrcmpr undrr s\-'r
<br />., --,L4i
<br />In.( r. \I rI l( )\
<br />IlNchy rltunutrdcr I)c dlryulFrltrry .trhc IollowirB dcclararior\
<br />-lhavcdrdwillmn
<br />ain, Ccrlric.lc ofConscnl to Scltlns!ro lor sorkcr'.otrrpctrs.rioD- rs pmvidcd fff bys..tion l70oolrh.
<br />ttrh{ Code. fq rhc p€rfonMftt orfic wor* for ehth lhc !.nnit is tsucd
<br />Ihrv.n dwillnrinrr workcrl conD.nssrion irsur0r--c- 3r rcqtrncd hySNriotr:t7lx)oIlhc ltrb.rCod., r.r rh. lirf.nmn.cof
<br />rh. w.rk forwhrhrhis Fflnil is hsucd. MyworkcF co'rpcnsrrn,n in\urk. .rricr orxl ,nlicy nunrbct m:
<br />Poli.y Nun$cr:-
<br />Icr ily lhar in rhc pcriornlnce.rrh. *oik rd shich rhi< r.rni n issucd.Ishnllmr c'nrn,y rny pcNon i..try
<br />'nanncrsr a\ tu bcc..r srbrccr ro rhc workctr' comlcnsdion hws of Calilffnir. Md lgm rh ilIshouklbc.omsuh,cdnrrhc
<br />q o*c* s'npcnsar ion rolkions ol Sstion :17(x I oi rhc llhn C{xI.. I sr, l. ronhq'ilh c.nuly sirh rhoqn,vhions
<br />WARNINC Frilur. b wurc workcrs compcnsdion co$ruEe N u.lawful. and shnll subjttl nn copl.rt, t, oinitul Fnrhics ind
<br />.ivil linc\ up k, oR hutrdrcd ofcomDcnsorion- damx.\ rr pr.vdcd lor rh.
<br />sr.rirn:1076 0frhc lrh, cr c
<br />I hcrlhy ilrrnrudcr pcMlry ol r)(co nncNltr+ wIh SNlion ?lxx))olI)ivisi{)n.]
<br />or rhc Busircssrtrd Pn' icss ion\ Cixlc.i aJd nyliccn{ i\ in tull fnr.c dcllccr
<br />L.cn.. ( ln\\-l-i..f\. Nlnrhcr:
<br />caNuaIlquQNrEND c-aclNcr
<br />t hcrby aflirn undd Fnrlry or p.rjury lhol lhsc taconsrrucrion hi ing dge .yr.rrhclsformlnceolrhc sort r(r rhi.hdi\pcrnit h
<br />isucd (Scc.3097-Civ. C )
<br />Aftulalll![cLA8arl0!
<br />I llnby,lli n undcr rctrihyol'|t iuryotuoIrh.nnl,snrAd..l diontl
<br />Dr nrliriM Pcrmils.Astcsios Noriiicariotr Fc,lcralRcgrhrnnrs frirb,10. Ptl6)
<br />Rcquncd htr.r ol Noririclrion
<br />lr.gubrions rcB.rdins.\bca.s rcnrvollrc not 3pplicnhl. t, rhtlrlcc!
<br />vcrcodlhnopplic ion,nd datcrhd lhc rhok inffimrion isconc.r I r8re lo d,nrPlt wir h dl Cny ond Counry
<br />cbsr rchtnB tobuildirsconslrucrion. dhcrchy,urhoriTr..frc\crl,lircsoflhhCnrrndCoufrytuctrrsulmnrrt
<br />9WFA.cLfiAa ^,",$[fth
<br />,,EI/T,NaDEZ
<br />DATE
<br />UFER Ground
<br />Subf loor/VenVlnsulalion
<br />Flood Zone Certif .
<br />Certilicate of Occupancv
<br />-)*-.-
<br />tJtrd.r's Ntrrm:
<br />-
<br />L.d., . Addr.q
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