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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BU!LDER DFJLCARATION
<br />I h.r.by rrfirn u d6 Itn y .f p.rjury rhrr I nm .r.mrr froE rh. Co.ta.r,m Li..6sc Ltrw ror dc following r..$n (S( r03 1 5
<br />3u\nrss and Prorcssion Cdc) Any Cily or coumy whi.h r.quies {inni' lo conslruci. !|ltr. i.urov.. i.mlnh or repat an,
<br />srrucrurc. prhr ro irs hsuuncc. aho rcqut€s rhc uppliclnr for such pcmir lo filc r sisncd \r,rc $r Ihr{ h.or shc is licctrrd pursurnr
<br />ro th! pnlkions of lhc Contraciols Ljccnscd L.$ (Chmrcr 9. Commcncin8 *nh Scclion 7(xx) ot Dirisn,n I orrhc Bu\in.\s a.d
<br />Prufc\\bn\Gdc)oriharh.orsh.ncrcoirrhcrcrrodnndrh.ba\isforrhcnlk8.d.rcnprion Anyviold noiSEtion7031.5hyrtry
<br />{pli.rnlforapcnn,lsubjc.klhc.mlicarlro.civilpcmlirornotnnrclhitrlilchu rcddolh6 (5500)
<br />I. r owtur.frhc pn,Fny..r my cnllloyms wnh wrg4 a\ rh.t v'tu .onrpci{ iotr, wrll do rh {or* and rhc {nduE i nol
<br />ic.dcrlor.,tcr.dforsrlc(Ss.1014.BusincssrndProltssions(lodclhc(lnrr.ror'sl.iccnsLiwdoesnornpplybrno$icrof
<br />rllc fl)lxny sho buildr or nnpmvus rhch,n. did wh doc\ ruch u)* hnhiclr.r hcnclf.r lhmugh lris or hcr o*n cmpbtcc\.
<br />pnvidcd rhar {,ch inpDvcmnh m nn inrc !\lorolllndfitrsah lll k,tralcr. rlr 6lildin8 or nntbrmnr is sokl wirhin onc )c{r
<br />ofsnrl)ldion. Itf, owncr BuiBLr Billh.!r rtE hudctr or liovir8 thlr lx Dr shc dil mr h,ild or impmvc rhc pR,pcd, rq rhc txilb{ or
<br />-1.
<br />N owrcr oI th. lm['cny. am crclusively conrrocriry sirh lic.n{d conrrx.xrn ro conddcr rrr ln)jd (s.. 7t}4-L Bustrtss
<br />nnd Ptr csi{,Codc:ThcC.mrackxsLicenscljsdocsnoraptlyba..wncrolpri,pri!yuhobuildrornnprovcsrncrc.n-
<br />a who conridslnr such proi:cls with i (bnrrodonI liccnkd pumlrnr rorhcCoirla.i(r'sl-iccr* lrw)
<br />I 'n.xchtrr utrd.! S..rn,
<br />Ornerl
<br />lll)BtrrBli]l.:ollflrNlallllN
<br />I2EIIAI/I.IION
<br />I hcrchlrr'firnuDdcrtcnrhyolpcinrr_orcolllEtullowiredcchrrlions:
<br />I h \rr wnl roinrain ! Ccdirlirc .f Conw b SclilNurc ld *orkcn .oryf,nsrit[ rs B)ridcd &r hySeri,)i.]70Ootrhd
<br />tihor Codc. ro.rhcpcrfontml{ofrhc *ork lar sh;.h rhcFnnir is i\{cd.
<br />-l
<br />hrv. s.n vill 'Einllin uorkcs comFnsalion inslEEc. !s rcquircd bySErion lT0oofrhc bb.i cod.. ror rh. pcrfnmm of
<br />lh. rcrk for which rhis p.nil is isscn. My wolkm' compcnsdi.n insuratuc ori4 !.d p.licy nunbcr trc:
<br />c'"''' '..s.-E*t (<"--2
<br />.a?l.r€-593 \- t --2sr7
<br />I ccnify rhrr in rhc pdfoflrEftc r)f rhc work tur rhkh rhn pc nir N issucd.I shallml cflrnloytr.yp€ron inaoyoan.cr
<br />s is ro lx.onE subjNr r' rhc Borkcn compctrs.rion lars ofcrlilo ria. rnd ll8rcc rhar ill shouid lr.o E ilhFr b rl'.
<br />wor*ch .onlp.nr ion nn,visions.lScclio. rTlx)ofihc titsr Codc.ldmll. r'onhwilh conrdy silh lhoE pnvjri.trr.
<br />WARNING: Failxrc ro surc qorklm conrpcNnriotr .ovcra8c is unlawtul- rnd shlll uiid an cddo)$ k, Lrnnnhl lcndral aDd
<br />cA'l r'nc\ uf to.nc hundrcd rhou\rnd dolla r$1t(J.ut,,.\0dd r.n ro,hr
<br />S.cr'.{r ru/hofrhc L.bor Codc. inkrN rd J,orm) . tN \
<br />D,... . E \ \ -A; Eapprr*r,)4 f 'r-----
<br />con ol conqxf,srrn,n. dr'tu8cs rs fii,vidcd irn rlE
<br />/--.../'
<br />rur xLDIlcL EtrIlaN
<br />I trrhyxii'muDLicr porlry oftrrjtr,y ur ofrhc tulb$,rg dr(lrri($\
<br />I)ftrn)lirtrrn l,.nnik a\h!{o\ N.rir'crri(m Fr c.rl RrSrhri(n\ lTii r,10, Prn6)
<br />Rrqun d k $.1Mnifi.irotr
<br />Iccniiyrhrrrlrcltdcnlrcsuhrionsrcsa ir8 asbcn.! rcnrql c ll'n {rlicrhh b ihi\ pn,j.rr
<br />l.."ilyrhiIhr.rcirhnllpll:cxri(nuxl{xrrrhrril'.rho{ilnnnrt{i!nrrc.rIilreh.DUly$lrh!llCiryrnn(iiunrl
<br />rr.\.lrh\(iry rl(inn \ n).nr.' ut rh.
<br />g-\\--X\jtE,
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Ereclion Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation A
<br />Rool Sheathing Y //Ut4 .*4)t"
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />t I
<br />FINAL filtnltl f-Mnt*L
<br />Certificate ot Occu anc
<br />Notes, Remarks, Etc.
<br />Shear Wall
<br />LII]DII,IEDIIINIIACIQB
<br />IECIA8AIION
<br />I harh, ailm undcr pcnrh, of Frjor, rhr I am lift.$d rn<lcr poli\ir orchnrrd 9 (.ommEin8 wilh Scclirn TUIO) ofDivisiotr:l
<br />ol' lhc Busim$ and Pmlcs\ions Codc. Brd my liccnsc is nr tull n{a aJit crlNr
<br />n,r".5 rL1 -:r-,t-
<br />IONEIIIqIIQNIENDN!.AGINI;}
<br />I h.rbr rflnn onder Foalryorp.rjuryrhr rhcr. ir a.onsltucli.n lcndm8,Bcn.y for thc tE ornEnceoflhe *ork forwhichrhisl'. nir h
<br />hsucd (Scc 1097,Civ. C )
<br />txndcr. Nartr
<br />-
<br />Irftlc''c J,ln\.
<br />,\|lr)!i.!nl {r lrrnt Si*..lurt
<br />,..,/r--zt4qt+,E-
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