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BUILDING. INSPECTOR RECORD
<br />SITE.WORK ID/SIG.COMMENTS OWNER BUII-DER DELCARATION
<br />I hcfuby .fllnn uM$ Nnalry ol lcrjury lh l 0n cicnpt lio'n lhc C.nrr.roF Liccn* Ltrw ior rhc hlnr*ins rc $n lscc 70ll !
<br />Burincss oRl t'roli$nin C{nlc) An, City or Couniy *hich rcqun $ Fnnir lo conrlrucl. llrcl imPolc, dc'fl,l1sh or RrT€n n,
<br />\rrucrurc. lnior t, irs i*itrr,f,e. als. rcquies rh.npllic.nr tor such Frmir ro l]le ! rign.d iaicmnr rhdr hcorsh. n liccnscd llrrurnl
<br />Io lhc tmrisions of lhc Conlracrors t-i.cn\crj L'w (ChrPrs 9. codmcrtirrS wilh Secrnnr 7000 of Divi\iotr I ol rh. Bnsincs lnd
<br />P,ofcs\ioisGde) orrh r h..rsh. ircxctr,flrhchno r dlhubo\krbrlhcallcscdcrcrrrri{nr.Atryvid,rn,nolSccri,nrT0:]l5hytrn,
<br />rpplicad rdrpcanir suhjels thc aprlicanrlo!(ivilpcnalryolnor ttrc rha fivc hnndrcd dolloF ($5(x))
<br />l. r\ owndr .f rh. ln,rrny, or my cmnloyecs with woscs rs rhcir sok co llcn\d ion. will do rhc woA dlhcntrruro n mi
<br />i ctrdcd or olltrcd tbr salc ( Se 71144- Busincs snd pmacssn,ns CGlc. Thc G r.clolst,icctrrct wdocrnor.nlilyhnnowncrol
<br />rhc F,pcny sho hoilds or imprcvcs rh-Mn. and who des srrh worl hi'n\cll.r h.sclfor rhrcush hn or hcr ostr c'nlk,r.cs,
<br />providql rhlr su.h iarpn,vcnrn6 m 'i{ in.ndol.r ofic6d tur *rt.li honocr.lh. huildiq or ifrpro\tdnt issllrirhinon ycE
<br />or c.nll)r.rion, rhc Owmr Buildcr will hlrc rh. hrdcn of povins ltu tE or \hd did fr, buikl ot inprerc lh. F'Pcny r.r rh. N{Ds oI
<br />l. rsowncroilhc flopcny. n c(ltrsihly.onkd ins wirh li..n*l cotrtrkkns ro con(ru.r lhc pr+cr (S(. 701-1, Ilusnc$
<br />ld hnfs\i,n Cod.: Thc Conkrctols Liccnse Law des nor ap,'ly b an o*ncr ofproFny aho l,uilds or nnpn,k\ rhcr.\,n.
<br />ond who conrBds tor skh tr,tccr\ wirha Contd.tun, li.cn\cn puruanr ln rhc C.nrrrctr's l-kcn{ tn*)
<br />(-scdi{r ru"/{"t!--"-qic
<br />D[rlAaa.IaB
<br />I hcrchy rlfirD undcr p.mlryorpcruryonc oflhc f ll,)wi18 d$hrrrions
<br />-lhavc
<br />ond will nuinr,in a Ccd ir*.rc ot cotr*n' b sclf.lnsu.c ror worl cr' co mpensar io.. ns povdcd lor bySc.rion 3700 orrhc
<br />tjbor Con.. tu lhc pcrlonurcc ol rhc {ork fttr shi.h rhc lcrmii is ksucd
<br />-l
<br />hlvc and willron'ui'r workcrs .onlcnsarion inwramc.,s rcqutcd htSffrn,n 1700 ol rhc bt{tr Codc. lbr rhc ,x 'n,n'ri.. nr
<br />rfu wo.kf{nehichrhi ll.rnir is ilsk{. My worlcF .onrrcn$rim insuran.. crni.rtn Fnicynumbcr !rc:
<br />PolicyNun$cr-ErPnc\
<br />I.cdi,yrh nrrhc lcrfoflnanccol rhc w.rk ln *hichrhis p.'j i\ nslcd,I shrll rol cnv'by ofy pcAon in ttryn nncr
<br />yr 6 ro hcconE \!hj.d io rhc witrkcn con\pcn\diotr lnwsofCrliloirrio. nnd trsrcc rhd irl sln,uld b..o'N n$jccr ro rh.
<br />*orkcr\'compctrsrrionpn,eiln,isofSc.lionllmrlrhchhtrC.d.-lshrll.fonh$irh.rnqltwirhthotPrevisn'ns
<br />WARNINC llilurc ln s.-urc wo.kcri c.n .n\.rn n .ov..JBr ir utrldsful rHl \hall suhr.cr r. cmPk,}!r r. aiNmrl pcmtics rnd
<br />.ivil filcs ut ro om hundred rhou\and dollu\ (S100,ffn). i'r rddirioi nr rlD cosl oi corrlcnernnr, dr qlcs ar nov cd for rhc
<br />:":-,itE"Tp*-":il,12 c!-o; )3.!t*9t
<br />Lrd[ rN* ll ( :tlN rR^('T(,R
<br />DFtt aRATI()N
<br />I hctoby rlrirrundd pctrrlryolfErjury Ihrl I !m licctr\cd undcr novnion ol Chtfrn 9 (connncNin3 wilh S$ri(r 7(x[) ol Divirnr -]
<br />oi rhc lltrsirc$ rnd h.l.*kJnsC.dc, flrd nry li.cne h in tullforen lclllcr
<br />AfILLCANUIiELABAIIO!
<br />I ffi'ylfrnnundcr pcnallyof ptrjnryonc.rIhc rrrllsirgd.cltrt,rions:
<br />D.ftri'iotr Pcirnils.Ashcsros Nolificorion [edcrll Rcs!hrnna (lirl. 40, Pd6]
<br />RL\tuircd kncr of Ndificarion
<br />I.c'rillrhi r]t lrd.'nlrcgrlrri,)tr cgtndltr! r.l{n"srrtrtrrrixr. n.r.r n'rxl,tu n, rl,n f'(r..r
<br />l.cnilyrh0rlh^.rc l rhis.folicdmn md xhrc rhnllhe fi,vc itrri)rturi{,n N.onLrr I rtrc. b comnlJ wirn!llCirr"rtrd Coufry
<br />ordinan.cs a d srarc Ltrw\ Eldi.s k) huildins connrudion, md hcrchyxurlntri,c nlx.scnririvc{ ofrht Cir, and Counrt k) cnrd uFrr rrt
<br />*," 8.t-l(l; :.,:,-::,,-:;. l* ; ?a"o; )tr)! .,-$
<br />.crn,i,e. nntr,.,,,rin,,: EJI )<. G.r( lcrdo
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/Vent/l nsu lation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framing 14 e sr) <<z/A TDi CA:?-b Cluqfi
<br />lnsulation/Enerqy
<br />Drywall )\k*
<br />Ext./lnt. Lalh
<br />Brown Coat
<br />l\4aso n ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Reporl
<br />Flood Zone Certif
<br />FINAL t0t o L/A,rA )
<br />Certilicate ol Occupancy
<br />Notes, Remarks, Etc
<br />DATE
<br />-T
<br />CQNjiIIII(:IIOI{IENDTUjIIiINII!
<br />Ihcrch,rflnnund.r|xrlryofpcrjuryrhnlthcrcisrcon(nrcrionlcndinE4ci.yntrrhcFrturmrnccolrhc$ortr(trtrhi.hrhisl.rnriril
<br />i\sucdrScc l0g7 Civ C )
<br />t ndcr\ Nrft:-
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