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BUILDING. INSPECTOR RECORD
<br />SITE.WORK ID/SIG.COMMENTS OWNER AUILDER DELCARATION
<br />I h$cby ilfifln uM.r pcnrlry oI pcrjury rhsr I am eicnrpr lmnr rhc conrr.toF L-iccnsc tiw lor rhc n,lluwi.8 rc.Y,n lSN.1Dl.5
<br />Busnr$ .lt Prulcsion Codc): AD, Ciry or Counr, whth rcquncs , pcnnir ro con(rucl- alrc.. impiovc. dcnDlnh o! rcprt any
<br />sructurc, uiorro irs hsuamc, llni rcqtrncs rh. +pli.rn( nn ruch Fnnlt lo filc! tisicd sllreffnr rhnr hcor shc n liccnscn PuilDrnr
<br />ro rh. pmvhnn* of rh. Contaclols l-icen$d tir (Chr cr 9- Commcncing wirh Scctiotr ?0(XJ of Divi\tnr:l ofrh. Bu\i.c$ and
<br />Pn,fcssi.nsci.)orrhdtEorshchcxcmpllhcEfromlndlhcha\isfurh.rll.s.dcxcmption.Anyvi'llri(,n.fS{tirtr70ll5hylny
<br />lDplican' lor r !.nnir suhjc.rr rhc lptlic,nr k, a cilillc.rlryornor trsrc lhln fivc hu rcd dollrN l$51D)
<br />l.asowncrolrhcJrmlrnr.olnyc, oy.c{wnh{r8c\ rhctr $lc comp. nqrion, $ill do rh. *.rt .nd rhc srrru i\ nor
<br />inicndcd orolltrcd fitr eL (S(.?(x4.3usirc$ otrd Prolcsio$ Codc: Thc C-ontackr's Liccnsc bw doc\ noltrnPIy ro rtr owtrq of
<br />rhc lrmtf,ny qh() ttrildsor impr.\rs rhcm)n, a who doe\ {ch ktrk him*llor hcrcltorrhbreh lrh oi hcr own cmploycc\.
<br />pmvid.d rh,r such i'npn,Ermnrs rrc mr iflctxhn or ofibEal lnr \ak ll lmqcEr. rhc huildin8 or imfolc'nir is lold *iihir , r( )tr
<br />ol.omplcrion. rnc O*kr Brildd sillhnvc rh. burdcnoftovin! rh hc o! +c did En h{ild .r iqrevc lhc pr'tcny fff rlr N{rr*.1
<br />L n\ oqncr of rhc F,tf,n f, rm cxclusively conrr&rinS *ilh li.cn*d cont&t)^ t) $trslruct tl'c Pmr--i ( Sc. 7U1.1. S nnc\\
<br />rnd PNL\sir.(ldc'licConrrack,\l-iccn\cLasdocsn r rltlykr rnorncr oln(),rc ywh. buiktsor imProve\ rhcrcld
<br />nnd *ho o Lrd: lnr su.h tnoiccrswilhr Cotrrraclo(s) lncr\cJ lursurtrrk,rtu (i rrrcrois l-iccn\c l. s)
<br />lrrrx.rt Ln .r Sccriinr .ll&l'( ntrihnr.r\r,
<br />I)5le: OBn.r:
<br />WORKERS' COITPEM\ATIoN
<br />IIDILIAAIIOtr
<br />I h.rchy rltirnrlndq l).Mlry or|xrjuryonc olrhc tollowinr dcclffnri.'ns:
<br />Coic.li,rrh! p.rfoirun..ofrhc {ork litr which rhc ncnnir is isucd
<br />uorkc6 cooDcn\rri{,n in\trnkc. as rcquircditSc.li,DllT(x){)lrh.lihtrCod..forrhcpcraonnu.cof
<br />nnir n i\\rd lly sork.r\i$ri,fl Nunncc canicr r flni.yno,h.rr.:
<br />/2'
<br />-lccnify
<br />rhar in rhc pcrfortuncc.frhc work fd w[a.h rhis Frnir i\ issucd- I \hrll ior cnlt'loy.ny Nr$a in rny nfftur
<br />s$robc.onEsul,j.clrolhcsorkgicor!.n\arionlafforcalilnrnir..trdlstccrhllillsl$nklhc.om.ubjccrlorhc
<br />rvortcn coflrNNriion povnioni ofSccrion:1700 ofrhc tihitr Codc.l shill. ionhs'ilh co'npl, *irh rhdc lovkions
<br />WARNINCT t:trilurc r,, \(ur. rorkcr(..npcr\dior .ovcrrlc 11 unln*ful. xfd \hrll cnnk,rcr r,).ri'ni'r tf, rlri.\ ri( , drnr8cs as pr)vi,l.{l nn rli.ci\il limr uf lo onc hundrc rhotr\r d Jo
<br />Scclion 3076 olrhc lrhtr Codc. i' rrc{ d d
<br />Dricr_
<br />I lrrchynift ruid.rFnrlryolFrjuryrhar Iui i'tr1.r |nor si,nol(h,iTtr L)r.!rnnrn. ! s h S..rn 7lx)i))
<br />oi rhc Bu\in.s rod Pi,,rdsi(nN codc. a Dyli.ctrsc is ir irllturerDdcrlccr
<br />,2'
<br />! hcEhy.llirnr undcr Fnrlryof|*rjury rh"r rh.rc i\ i.on{fl.tkttr lcndinE {cncy for rh. l)crfonun( oflhc sork lbr $hich rhi\ |tnnir 6
<br />i($cd(sL\ :rlr97.crv. c )
<br />afPl.IcINLDECLA&lIll)!
<br />I llnty ijtlrD ufttcr |rtrrhy ofpcrj!ry om olrhc i,lk,wi'rg.tcclnrrrun\:
<br />lxnmlir ioi Perdirs sh.n.r Norln.d ion ,i.dcrrl Rc3n [l i{N (l irlc 40. I' d6 r
<br />R.quncn l.rt..r Norli.rri(r'
<br />rh.r I ltrrc..ad rht !plliori(,n rnl {r. rhrr rh. rh,v. nr nr ic.orLsr I rgrs roconrlr'$nh rll Ciryrml Counry
<br />izc rcprc{lrlrivc\ olrhi\ Ciry.rd counr! ro cnrs umn rhcoidir n.cs rod Sr cIiwsrclaringro hrildinB
<br />rtxrc mcnri{,.cd pn,t)tny rd ins
<br />;," E-:s-1f
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Rool Sheathinq li btltr €,Uhzr- /R)
<br />Shear Wall L",
<br />Framinq
<br />lnsu lation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lt/lasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif.
<br />I
<br />FINAL Vlto fiP' I 't'rntw th-
<br />Certilicate of Occupancy
<br />Notes, Remarks, Etc
<br />DATE
<br />Set Backs
<br />UFER Ground
<br />Subf loor/Vent/l nsulation
<br />lf, Jci( AJtlr.s':
<br />-
<br />_l ccniiyrh rtu ttdrrrlrctul i,nN rgrrdr8ashcsros r.nF\nlrrc nor rppli. blc h rhi\ pn,tc.r
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