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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />Subf loor/Vent/lnsulation
<br />Rool Sheathin s
<br />Shear Wall
<br />Framing
<br />lnsulation/Eneroy
<br />Drywall
<br />Brown Coat
<br />Mason ry
<br />Pool Fence
<br />T-Bar
<br />Handic ap Req
<br />De puty Final Report
<br />Engineer Final Beport
<br />FINAL l,/.-2/-18 ,.J/.&o (s)
<br />Certif icate ol Occu pancy
<br />Notes, Remarks, Etc
<br />oWNI]R BUN,DER DI]LCARAl'ION
<br />I harcby ,fltnr trndcr F-nalry {)i pcriury rhar I m cxcn{r fnrn rhc (otrti.ha I i..n\c lrw nn rhc n,lk*i,rt rc.\ r (Scc 70:11 5
<br />Bu\ r.\s .trd Prolal\ion (lodo) Atry C ry or C.udy whirh Rqun \ , |knnir ro.o qnrt..ller. irlrovc. dcnmli\h,tr rFntrn,
<br />nrucfurc. prioro irs h$umc. aho requn$rhc rtpliclnr lor nr[ pcr.rir ro filc tr \igncd nrtmnr rhri h.or shc i! li.cn{d nnruinr
<br />ro rhc nn)vhionr ol rhc Coflrrrcr.is l-ic.n\cd Li* (ch.,,rr 9. C.mnENlng $irh sccri{n, 7(Ix) oI l}ilisn,n I .f rhc au(in.s( a d
<br />Pr)fc\\i,x,s(irdc)orrharhcorshciscrc rtrrhcr.frorrnd rhc lx'\n f(n rhc lLg.dcxcrprtrri.Atryvi(,lilnlnofSccrion70:ll5byrry
<br />.fplicr.t ror. Nnnil suhjLrF lhc il)Plicnd r. ..iril t'cmlr! or Nt nntrc rhrtr lirc hundrcd{lolhr (Ss(x)r
<br />-1.
<br />is osrcr of lhc pmpcn r-. nr my cnrplo)E\ *irh s!gc( $ rhcir slc comncnernn,. sill do rh. sork urd rh. imrurc i$ mt
<br />inr. rtl o'offcrcd lbr srlc (Scc?04,1, Brsincrsxnd Profc$ions Cods Thc Cin ract rLi..nscLrwdocs.orlrrnlylorno$n.rol
<br />lh.Jrcpciy who bu ilds or nwnrvc\ rlrNtr. ud qkJ dr*\ \u.h Hnk hnn\cll or hcmeli.r rhrouah nis or hcr o*n cmploycc\.
<br />nrovnhdrhrrsuchi.,pRr$rn6rcRnircndcdoron'c'rdhrsrlcllh.*srirhrhildii8ori'rpmvcturri\{rldwirhirotrclcrr
<br />ol .onrlrtlion- rh. Owncr llui[tcr *ill havc rhc 6urdcn ol prorin8 rhal hc or \hc did nor buikl or ir{ro[ rh. pR,r.it fd il* N{xJt .f
<br />_1. aiorrcrolrhcropcny. r'ncx.lu\irltconrracri'rg $irh licctrs.d c.nkrcnr\ k,co {n.rrhc fhjc.t (so 7Lrrl. Bu\iics
<br />nnd B!f.s\r'n Codc ThrQ)ntrctr-{ Li.cnsc Ld*docs nor rptlyro rtrowncr offn,t'! y{ho huild\ or imlDv.s lhrrcon.
<br />anl sho onrra.r nn $ch ptr'jrcrs wilh a (bntlcr.tr( 9 licctr{d nxnurnr h rhc contrtn\ l-tctr$ ljE)
<br />I r .r. Ir !tr{ls S(rio
<br />IAAKIIS:.(:OUI:ENSATI0N
<br />Irlr;taBAua!
<br />I hcrchy rlltnr urd$ p.nrll, of lcrtury onc oI lhc lhlk)sirE dc.lnrnrnnrs
<br />IhrvcindRrlltruir{maCcnili..rc.tCotrscfliloScll-1tr{trcf(,vorkdaconrcnnfi.n.rspovidcdlbrhyS.crni:]lmorrlc
<br />Lrhr Cdlc. fd rh. |frfonrun.c.t rhc w.rk r(tr qhih rhc Frnrir i\ ir{rd
<br />-l
<br />hivc ond sillmiint0in sorkcr' conrFnsarion insum.cc.0\ rcquncd nyScclion.rTmolih. trt'{ncodc, ftrrhc tlcrronnrmcof
<br />lhc work lorwhichlht pcnnit is is{rcn. My workcm' .onrrnsr ion iNumn(c crricrarlpolicy numhcr ad:
<br />_l c.dify rhrr in rhc p.rlorromc olrh. work ln *hich rhis |4nnir is issucd. I shrll nor.'ntltiy rny l]cMtr ir itry manncr
<br />e) * t, bcco rc \rhp.r b rh. qolkcs' ..nf.nsd ion lrws of CiliLarir, ,trd l8e thd il I should hcco,rc suhicr nr rh.
<br />sork.^' omp.n\d i(,n pn)vi\ir)trs .f SLrlion :17(r of rhc trhr Cudc. I \lull. fonh(irn coflrply $ irh rhos F,riions
<br />WARNING lailu.c io E.urc s,rkcts .onDcns idr covcnsc s u.hrnil. and \hnllsuhjc.r an.ftpk,Jtr t, ritrritulpctrrllrs rtrd
<br />lo orc hundrd lhousa doll \)). in r(l(liri,,tr r, rtu..n olrotrrNnsrrtn, a r!r!rsfn^trlc,llhrrhc
<br />brl
<br />I hcrchy {infl unncr pcnrlryoircrjury I n{n utrdcr Dr.vni.nolCnlpr.r I (c.mntn.inE firh Sccrih 7u)0r.f Drvision:l
<br />.l rlr Rtr(i'r's Md Prna*idi\(int. rnd nv I
<br />Ltt 04U
<br />I hcreby affirm under F"ahy oa lcrjury rhd hcr. h r annEctiofl lcndins agcrcy lor
<br />'hc
<br />pofo@kc or rh. w.rk for whth lhn lEmil h
<br />issucd (Scc lo9?. Civ. C.l.
<br />AfftrcaNr.aEcllf,alla!
<br />llx cr'yr nn undcr pcnrlly olpcrjtrry om ofrhc iollowing dccl0raliq,\
<br />Dcmolirnln Pcrnrils-Asbcslos Norilic.lion ljcdcml&c3ularions l'lillc4(,. Pld6)
<br />-R.qutcd
<br />l-cltcr oi Nol ifrdiotr
<br />I cflrilirha{ rl[ fc&rxl ,clrhrii)d\ trgrdnls x\l{(f\rcn(nrln'r orntt)lirxbl. i) rhi. t)r.tc(r
<br />rftrrion n conNr I a8xe ro orq,l, *irn lll Cir y rnd Cotrnry
<br />axrhorizc Eprcscnrari$s olrhis Cir, and Counryfu cnrn qa,nrhc,,,.1,
<br />KhdnDg
<br />Forms/Steel/Holdowns
<br />SLAB Floor
<br />Ext./lnt. Lath
<br />Flood Zone Certif.
<br />el?/
<br />8 ZZ
<br />rl,
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