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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE OWNEN BUILDER DELCARATION
<br />I h.rchy liltm utucr nenilty of Eljury lhal t oflr crcnur fo'n lhe Co.l,a.t,a Licnr lj* ror rh. rollowina rcr$n (Sa.rllll.5
<br />Btr\inc$ and ttola\snn, Codc) Ary Cny or Counry which rclun.s a t'crmn lo cotr$rucr. alrcr- itrrDlovc. dcmlkh or Enrt 3nt
<br />(ruciue. priorro irs hsuitrcc, oko rcquircs rhc.Drlicanl ior such rErmir lo filc a sisncd sdcft.r rhd h.or shc is liccnsd NNuant
<br />k' rhc Fovi\i{in\ ofdr Conrn trt Li.cned Law (chiprcr 9. connncn.inB sirh Sccln,n ?(l)O of Divnion :l orihd Bunnc$,nd
<br />Prolcsir)ns G)dc)or lh.l h.orshc tcxcmpl lhcrcfron 0 lhchnsis iorlhc allcssl crcn,lrn,n Anyviohrn,nofsccrionT0ll5hyrny
<br />lprlicsirior0l}crnritsubjd.krhc,mlicr ro,.iviltc0trlryofnorntrcrhrifilchundrcddolhs($5m)
<br />l. dr own.r.rrhc proFny. or nryc,nployccs with waecr as rhcir snc compcnsario.. willdo lbc sork lnd rtE nuim n nol
<br />inrc cd orollcrcd lnr nrlc iSa.?0.14. Busires\ond Proicsions Codc: Thc Conta.ktr\ Li.ctrs. Lawdocsml arDlybotrowicror
<br />rlE pn)r.ny wk, htrild\ or impmEs tlrmn- a sho des su.h wo* h im$ll or hcr{ll or rhmDlh his or h.r osn cnrfby..s.
<br />|)rovidcrl rhrr .r.h i'nfmhnEih m ftn intfrL{ 6 .ficE\l for slc It h.vct!r. rh! huildmg or inqmv.rnr ir rU wirhin .nc Jra
<br />of(nnplubn. rh. Owho auildd will hrK th. bud.nofpn,ving rlmr ltor slrc Llid mr huitl or i'npmlc lhc pn'pcir lnr dtc purFsof
<br />Ldsowncr.frh.F,p.ny.rm.x.lu\ivcly.onrrti,rtsirhli.cnscdc.trfuLronroconstrucrrhcprorccr(s(7(!4.Businc$
<br />aid lhr(siorCodcr TncC.trlracl,tr \ l-iccnsc Lrw docs olan!lyk' rn o*ncr ol pmpdt wh{) builds or iqrrovc hcrcon-
<br />r l who cotrrBc(ror su.h pmirrs uirh r Contra.tln \) li.cn\cd Nsuiir h rhc Cotrtr"cktr s Liccnsc lj*)
<br />I rrrcrc rl, u.{lcr Sc.r B & P( ntrrh^ rcrn)n
<br />D.t. Owner:
<br />woi(rRs' coMPENsAiioN
<br />DECI,AM.IIIIN
<br />I hceby aflirm und$ rcnlhyof rEiuryore ollhc follotrina d(lan(ionsl
<br />_1l'rvcund willruin[h, Ccniiiclr.oIcoi*nr t' sclr'ln\ur. li)r workfs ..,qrcrsrr mn. as Dovidcd for bySccri{nr]?([orrhe
<br />tIbor Codc.lor lhc rcrfoflume oarhc Nrk lbr $hichlhc pcnnir is hsucd
<br />El h""c anl *ill nBirr"ir *.rkcn .odtr \rri{, r i'Nur cc-rs rrqund hysc.tiot:1r(x)oirhc tnhor Corlc. ror rlt pc.ro nrd.cor
<br />rh. so* lor whichrhk pcnnir i\ t\ucd Mlworkcr'cotrlPcnsrrion i',\ufunrt.nricr tlNlicytrun$.r dc:
<br />lq< 7,, lrl 7
<br />c 7or{rz
<br />7-2f-rt ..",,*",t-6d rayJ A f6,e5
<br />CANIiIf,IJI]IIANIEIDIXIi.dGEN1:}
<br />I hcrchy rilnmundcr pcn{llyolpciury rhd rhcrc ir a d,n\rdcrion lciding ascmy r.r rhc nc'foflnrrc. ollh. sork ior shi.h rhr p.rmir k
<br />hsucd (S( -109?.Civ. C )
<br />A?TLIEAN[IJE.CIA8AIIIIN
<br />I tErchy amnn u ndcr Fnrlly oflcrjur, onc ofrhc nnhwin8 d(hrurions:
<br />D.mhnrn Pftnirs Arb.ios Norillcrrion Ftd.ml tusuhtnnrO lc 40.1'!n6)
<br />Rcqxircd txtrfi of N.rifi cdlio r
<br />_l.cnit$sr rhe ndcrbl rsuldridN rular'l g a\h.{os r. rvnlnrc nor {plicrble k, lhk F+cr
<br />f,(,, "nu,'r. r n * ^.,u'nh rmrrJ,L{, dd *c rhi,hc ihor.,' uld'nrm..Jndsr,rcL'u\rLrntr.hurld,n8.^n{rucri.1 indhcrch)
<br />nndi0 notrdi I arrR t .omply wnh all Cilrnnd Co!trly
<br />rurh /c,)r{ rr..,,ilhF c y Jftl coun,},o cnrF uP.n,h.ffih *,", J'LLtsxli)rc nknroncd t(r|xny 1rtr i',\pocrior purfl)sr\
<br />Applicotrtor Asetrl sisn!turc t(*/do-ffi
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsulation
<br />Rool Sheathino
<br />Shear Wall
<br />Framinq a/I
<br />lnsulation/Energ y ///2uLz .ry)M)i ')
<br />Drywall v 7'V
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lvlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Depuly Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />I
<br />FINAL ///zt/l*-&)
<br />Certilicate ot Occupancy /
<br />Notes, Remarks, Etc
<br />-,
<br />ID/SIG.COMMENTS
<br />-l
<br />ceniiyrhil hlhc,Erionn0nccolihc$ork furnich rhi\rcmil is issucd.l shrll tror .tr[k,y any ,crson inany mrnicr
<br />er r n, lEcom slb,ed b rh. $odcra c..rr.ns,r ion hws or callroari.. .trd i8rcc lnar il I slnuld ll.com h,cdrorlf,
<br />*orltrs conFnsarion pDlhn,nsofsdrn,n lT0oofrhc Lrhor c.d..l shrll.lonhwirl cotnply wirh rho* lrrovisi.ns
<br />WARNING: Failurc ro scurc workcs conDcns0rion .ovcnse is unla*tu]. md \hrll subjc.r rn..rrl,rycr ro sinriml prnlhics lnd
<br />.ivil llms up lo.rc hundrcd lhousud dollm rslct,ux)). nr uddilion nr rhc cod.r.o ltf,trsrriotr. dtnmScs os [ovidcd lor lhe
<br />Sdiotr 1076 ofrhc btrr Codc. intclc( and auorrcy s Lcs
<br />u^,", ' 7- 1 (- l* *r,..ll62na-u./n F/nrd_.!('!:NsFn ( oNTRACltrt- s /
<br />DECIdBAITAN
<br />I h.ehy rlltm u dcr pcmlry of pcrjury rhd I rn li..trkd und.r phvision oi (-hrtlcr , ( comrrcncing sirh S(ri,. ?ffD) of Dirisim l
<br />oI rhc 0usine$ alld Profc$ioni Gd.. and Dylic€n$ i\ in lull ftncc a,xlcrlc.r.
<br />L,1 J ',\ 'l.t'...
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