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BUILDING. INSPECTOR RECORD
<br />SITE-WORK ID/SIG.COMMENTS OIYNER BUN,DET DTJLCARATION
<br />I hcrcby aflirm undcr pcnrlry (,r pcrjuiy rhdr I am cxcnrlr fbo rhc (.onrrlcrql Liccnsc liw Lr rhc following rcrn)n (Scc 70ll 5
<br />ausincss anl Pn)fcsstun CqlcJr Atry Cily.r Counry which rcqutc\ r tc ir r. co.(n.t. rlrcr. inDnwc. dcnrolish or rc!!n lny
<br />(ru.ru.c- !!ior ro ns issusr(- aho r.qotcarhc aprlianr fd su.hlr.nnn rJ filc. signcd storcmnr lhlr h.orshe t licenscd pr*ud
<br />ro rhc UovlsioN olilE Corlruclor's Lianscd liw lchlllcr 9. ComnEncin8 w h sc.rbn Turo of Division:l of lh. Blsinc$ ud
<br />PmLss io ns Codc) or rhrl lEor shc n cicmrl rhc,crroo md rhc ha\i\ r{n rhc k8c,lcxctrrflion Atryvidoli!.oiScc'in'?0.115by,ny
<br />lprliconr forapcnrir suhjc.k ih. ippli.anr ro r.ivil!.nrhy.fno! morc rhn llvc hufrtrcd dolle\ (S5fi1)
<br />I. N ownfiofthc tioFrly. or ry clnployrcs silh urscs as lheir slc con{Ei\ar ion. willdo rrE work ffn rhc slruclm i\ .or
<br />i c.dcn or ollc.cd lor solc (S( ?Ot4.llusincss md t'rolcsi,,n\ Cudc l hc conrido. s Liccnr liw docs nor +ply k,0n oqNr ul
<br />rh. trmlEdy wh. huilds or inDmus th.Nn. 'nd wto dms {ch $.* lrinsclf or h**lf or lhrough hi or hcr .*n rnl.'loyccs-
<br />providcd rhf,r such improtmnh m fr, intc cd or oficEd for ek. lt', howstr, Ih. hrillinB or i'n mvcm n sU $irhi'r onc itd
<br />ol coq"lclinr tlE Owncr Buitlcr sill h,w rhc hurdci ot Itroins rhd hc or shc dA llol build or inFmrc rhc poFdy fot 'rr
<br />puqb$ oa
<br />-1.
<br />a\ own.rolrhc ropdy. amcr.lnrivcly.oftrcrin8 pnh liccnscd conrractrs ro consrflcr rh. ln,lc.! (Scc.7()+'1. Busncs
<br />nnd hDfc$hn c.dc ThcConlrocroist-iccnscLawdocsoorapplyro own.r of Prcrny who b! ilds or inrprorts rhcrmn.
<br />rnd who conrBcsfor ruch pn,jcb silh r co n b(rlNrscdl{nua ro rhc conrrncktr\ t-icc.sc tiw)
<br />lrm tr.f,!r otrLl.r S.rri,)B & PC hrlhisr$nn,
<br />Dal.: O*ner:
<br />WORKEILS' C'()IIIPtrNS,tT!ON
<br />lzEl:llaA.Ilo!
<br />I hcrcby arfirm!.d6 pcnalry orpcrjuryom olrhc followir8 dmhralbnsl
<br />-l
<br />nlve aBl r ill Eiorrin r Crnificdc of Co \cnr b Sclf tn\urc ftr $orko i c{mpcnsrrin. r\ prov dd for bySccrion:17(x)ol rhc
<br />Lilnr Codc. for lhc Friornramc oflhc iorli lar whichrhc prnnir i\ i\\u.d.
<br />-l hrvc udwill mrinl'in *or\crr comltn\rrion nr\urrn(. r\ rcqurcd bySc.riotr.l?rx)ol ihc l-ahtrcodc, ror rhc ncr,hnnrnceol
<br />Jr N n<uftl Eftnk.t o
<br />'tcn\.hon 'nsu.trRccoricr lrdrlty numh.' m
<br />z Pu-"/
<br />-Qr7/?t I 6,) i
<br />I (nify rhd in rh. l.iio.mkc.lrhc work f{tr *hich rhir t mir is i\\uctl. IthrllhrcnlPloy rtry pcsotr in ony m mr
<br />s .\b h€onr $hjccl rolhc workcriconycn\arion law\orCalitunri( rtrd uerld iIl \hould hc('m shJ.d brhc
<br />workcts co pcnsrri,,npovti{,ns.lSccrnn,.l70O.frhcInhnCod..lshill.linhwilhco'nplyuithrh,sl)n,visi(,n(
<br />wARNING: F lurc lo scurc workcs .om|Enr i('! covcri i\ u hsful. rDd shill nrhjLd {r crnbycr t,5i'nnd ff,irlric\ rid
<br />.ivil lrtr.s up to onc hundr.d thousund doll ldiri('i b rltr .o{ oi corEnsnr nr- drnhE.\ r\ p'ov'd.d lnr rhr
<br />S..rn 3076ofrhc Lahtr Qnlc. inlcrc( d '9*-\,?Oo-t
<br />LttErtriL()Lut&la[
<br />DXILI&UIQN
<br />I hcrcbylllirm unJcr pcnslry oftcrury rhd I rm li.ctrsol utrdcr tmvhion oiChrprs 9lcommncing wirh Scrhn 7l[0) ol Divi\ion:)
<br />or rhc Dusi,rcs md PmltssionsCod., aJ nyliccnsc is in full r.r.c Dxl clT.cl.
<br />o
<br />a-r 5 Czrs
<br />g.)!$LlJcllrlllENDlNclcENcr
<br />I lErchy rflirm undcr Fnxliy or t rurylh,r lhcr.is,.onstdcrion h i"s.scncyforrl'.!.ni,rtuicc.rrhcworkn,whichlhnpctrirh
<br />n\ucd (Scc 109r. Civ C )
<br />Lrndca\ Nrnc
<br />AITIICAILIIECLAAAUON
<br />I H)y amnn utrdcr,rcnllly of pcrjlr, om ofrhc aollowins dccldarn,n*:
<br />D.n{lnion P.nnir\ A\b.sl.s Norifi.ariotr lcdcral Rcgul.riotrs (Tillc40, Purl6)
<br />-Rcqlt
<br />d ldrf of Norificdi,.
<br />l.cniryrhar lhc fcd.r! I rc8ula r io.s rcsadnrs !\lEsro\ rcn'!rl lrc ornmli.,blctJ rhisl)lo]ctr
<br />-l
<br />ccniiylhal lhNc rcld lhhrppli.linMd nrrc rh{ rhc rh,vr i'itunt(trtrr i\coiiccl lrEech$'nplywirhillCiryrtrdCou.ry
<br />ordinomcs and Stalc liws rcldinsro ildi+.oisfldn{ rd hcrchyourhoriTe rcEcscrlrrivc\ ofrhi\ Ciiy aid Counly ri cnlcr uF)n lhc
<br />,hovc h*nltr)ncd lm|trty f.r irsr
<br />,\DDli.trnl or A[.nl SiEtrolure k 7-<n./?
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lns u lation/E n ergy
<br />Drywall
<br />Ext./lnt. Lath
<br />l\/ aso n ry
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL
<br />Certilicate of Occupancy
<br />Notes, Remarks, Etc.
<br />DATE
<br />Subf loor/Venti lnsulation
<br />Brown Coat
<br />,
<br />Pool Fence
<br />I
<br />L'*
<br />GtrCcr'. AddR$'-
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