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BUILDING- INSPECTOB RECORD
<br />SITE.WORK DATE ID/SIG.O1VNER BT'II,I''ER DEI,C RATtoN
<br />I hucby trllnm undcr pcnalry i,, ncrirry rhd I m.rc.rpr rro ih. Cirntactor' l-ienrc ljw for drc nnbsinC icrk$ ( Scc 70l l 5
<br />Blsinc$ and Pu'lcsio Cod.): Atry Cry or Counry vhi.h rcqun s s [lcnnt lo cotrdtuci. alrcr. n\,rct, dcmlirh or rcPun m,
<br />sfl.ru'd, rnrr. ns hsuin.c. ako rcquirus lhe apflicrnl ,ir such ,cmir lo ilc " signcd e{cmn rl hc or shc n lir.n\cd fltumr
<br />h rhc nrolhion\ oi rhc Conrrackn s l-i.rnscd l-ns (Chnpr.r 9. cu nncmins rilh Sccrion 70(J0 of l)iviln l oi rhc lrusirrc$ rnd
<br />Profcr\iors Codc)or rhrr h.or\hc ircxcmpt rfurcfrunr.nd rltr hsis rb.lhc lllcsctl cknrrrn,n AiyvidarionolSccrionT0ll5hyrny
<br />nf,Fl nr rd,r(mrirsuhiccrsthc ap,rlicrnrro rcivill]cnrh) olnor nrr.rhnn riw hundrcd dollns(S5u))
<br />-1.
<br />ns oNncr ollhc Is'ttnr.,tr hr.nDk,ycc\ sirh wrBc\ a( r[cn {nc co rt^-trsulioo- silldo rhc solk nnt rlt drcluE i\ nol
<br />it ctr(lcd or orTc' rd ntr {h r so 7t!4, Busircs nM Pn,fc$nnrs Codc l hc Cofkrtr\ ljccn{ Lr* d.c\ trot E fly k) m o*ncr ol
<br />rhc pnlrny *h. hilds or iDtroB lheon- ul wno des such uort hi'nielfor h.^cllor rhrou8h his or hcr osn c'nploycc(,
<br />l)oridcd rhrr rD(h i'nFn,vcnrrh m Nr n cdd ur oIIeE Lr \rlc Il how.vcr. rh. h! iklir! or i'n[.1tn. is5Hwirhmom)tr
<br />oiconlrldion. rhc Ostur Btrikld willh.w rh. hud.foffmv E rh.rh.orsh.did nor buikl or itr9rcr. rht FJpcny foi r[. pu4r,{.1
<br />l. asowtrcrolrhcl]fopcny. rmcrclusivclycotrlEctins $irh lic.n\cdconknd(r\k,.on(ruclrlE rn']e.ris.c 7(|l4, Bhim$
<br />lnl hrf!:(ion Co.lc:'l hc Conrrrckr'\ Li.ci\cL.wLlo.( ior.l)tlyb 0no*rcr ol pr(,pcnrwho huiltls or i'nfroEs rhcrcon.
<br />rnd who..nhcr\li,r{rchprol.cr\*ithrC.nrraci{n(nli.ctr{dpu'\u. turhcGdrrrrtr\l,iccn*Lf,sr
<br />l.hcrcmDr undc.SNnoir B &PC rorrhtrrc,\nn
<br />Date: O{n.r:
<br />woRxFns' col\tPFNsaT()N
<br />AEI.I,/IIAIIO!
<br />I hf.by rfirni undcr |r.rlry olrcriuryonc ollhc tullo*inp dcclrrnrtntr
<br />I h r dld * ill ruintuo a C.n ifEarc oa C.nrnl ro Sclt lnrtrrc tu sokcs .onlrnsd ion- ts nDlid.i nn hy S.ctio. 3100 of rhc
<br />hbor Codc. for rh. Frlnrmsm. ofrh. Nork for which rh. pcmir k i.socd
<br />rlrr s!rk 1,tr sl,i.h Li\ t).'n,il 0r irtrrr)D.c.r'ricrrRl |x)li(] nu iirr n,.
<br />l.cdifyrhal in rhc p.nirnrrccollhc *ork,nr qhichlhk |Ennil is hsucd,I sh0ll not cnrrloyrnytcson in rnynrtrm,
<br />$ Nlo hcom subjcct to rhe sorls\ conFtr{rion l,ws orcrlilorna. and asrec rhr ifl *hodld trtDnr subjsl lo rhc
<br />wo nl con\tnsatn rra,vnionsofS..!n,nl?(Dofrhc btrr d)d..I shrll. fonhsirh codply w irh thoe pmvnions
<br />WARNIN(;: Failurc ro surc workcr' conq{nsalion covcmgc is !trh*ful. nnd shdl sul'i.tl !n ctrlllk,}s b dnxnrl ,icmlta\ a
<br />.ivil fin$ up ro onc hundr.d rhoNlnd dollds ($100.0mJ, in addiri,n ro rhc co{ o! cotr{Enslrnrn, danug.s as Pnvidcd io! rhc
<br />Sari,r 1076 orrhc L1h, CLic. inrcrcn and inormv'\ fcc.
<br />i.,,"",
<br />-.""Wi,?" -;;-; tuxt'*, stkar"/',k/ LtclNlfn coNTR ( "lull
<br />IECIAMIIO!
<br />I herhy offirdnndcr ll.nllryolp.rjury rhd I n li.cng'd undcr I'mvisnrn olChdlld 9 (.ommrci.s wirh Serion 7oo0) oroivi\n,n l
<br />ol rhc Business lnd Pnfcs\ions C.dc, ,xt my lk.n* h n rull r(,.! mi ell(r
<br />8,J/e18 .-,.*".(
<br />Ihcrct'y,fflnhurdcrpctrlhyol!.rjurylh rhcrc n ! on{todi,n lendine rgcrcy aor lnc Pcrforroe..rrhc work for $tich rhn lrrmi n
<br />issrcd (Scc 1097. Civ C.).
<br />AIILLCANLDEUAB.{IIQ!
<br />I hR$y !fiinn u Md ncnulty oI pcrjuryoi. ofrh. followin! dNlrariox:
<br />Dcnrniidr Pcrinits.Arbesros Nnrilic.rioo FcdcralR.guhrion{lTirlc,l(). Pon6)
<br />RLlutcd Lxcr of Notifi c,lioi
<br />-l
<br />ccnily rhd rhc rcd.fu I Egul,rio ns rc8udin8 asbcsos rcnn,v(|rc nor amli.ahh ro lhr proJcct
<br />P;",,,,:*l hrc rc r[is lfp]icarionMd .rhr rhcrlx)!. i'rlo'trrrri(fl is..rr.1 Ix!r.ch..tr,t,ly(irh llCiryrrl((rn,lv
<br />rrc Lr\s rl in! bhuildirr tiotr. und hcrcby drhorizc rcprcscnhlivcs ollhh Ciry dd Coxnryto cnlcr ulnrtr lhc
<br />rhir nrcnridrd rmFny rnr in\t^-.rnr rurB)sc()'-'-
<br />^ppli$nt
<br />or Asenl sisnslure K e ""r.W
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVl nsu lation
<br />Roof Sheathinq
<br />Framinq
<br />lnsulation/Eneroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />lVasonry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />l--
<br />FINAL Y//r,lrl /,-YQIL
<br />iCertilicate ot Occupancy
<br />Notes, Remarks, Etc
<br />-)
<br />COMMENTS
<br />Shear Wall
<br />Pool Fence
<br />tindn r Addr.$
<br />-
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