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BUILDING. INSPECTOR RECORO
<br />OWNER BUILDER DELCARA'I'ION ' -I hcrchy rfilrm undcr pcndlly of ncrjuly lhrl I rr cxcflrnl lmm lhc Gnrracros t-icensc L* nx rhc rdk,*ing aiwr,s..?ori5
<br />Arsi',cx and Prolision Cdlc): A.y Ciry or O,u y which rc+n.s a ][n r b coDrnrcr, rllcr, nnprovc. dcnDlhh or mprir'rny
<br />ifl.iurc, prif b irs i$uM.c. rko rcqutcs rh. rptli.anr forsu.h F.mi h lilc r sisncd {ntnrnr thar ltor shd i\ li.cnscd putsu.nr
<br />b rht F,rhnnN .i rhc Conrr cttr s t-ic.nscd l-aw (Chaprcr 9, Connncn.nrg *irh Sc.rion 7UX) of Divhion :l .f lhc 8!\incs nnd
<br />Pmlesions Codc) .r rhar hcorshc ircxcmpl rhcreiroNontl rh.basis for rhcallqcdcxcmprion nyvinhrionofs..hn?0ll5b!rny
<br />applicr nx a Fnnil subjccls rhc !pplicanr ro acivilpcnalryofnor nrrcrhan fi!. hundr.dd.lljrs(S500).
<br />L a\ oerr or rh. pDFdy, oi my cmpl.yrcs wnh waacs a! rh.n oh .ompcn{lnnr. will do lhc work ud lhc slndm i\ nor
<br />inrctrdcil or oltcrcd lor sk lS(.7044. tsusnrcss and Pmlcsions CoJe: lhc Conrrrdoir l,iccn$ l,w docs h.r amlr lo rtr owncrof
<br />th. pDFny *ti) bdikls oi i'@m*srh.dn.ed whodeiskhk)* him\clforh.s.lforthrcuBhhis o! hcr own cmployccs,
<br />Drovidcd rhll such impmlcmnls N frn iDhnd.d or oltmd for soh ll hou$cr, rhc boildin8 or iqroknxnt k $kl *nhii nnc ,u
<br />of.omplcriotrrhco*icrBui o will tuE lrE brd.tr ol povin8 rh,r hc or shc did xn buitl or i,ryrorc lh. pm[td! t& dt ruqr{ or
<br />-
<br />l. ns owmr oi rnc [oDcny. oar ciclusivcly conrtscr ins *irh lietrql conk!.ro6 lo con(tucr rh. pmjcd (se 7(144. suinc$
<br />,nd [h,f6sbn Codc: Thc Conkd.a\ Li.cnsc Low d.es noi aprly kJ ,n oRncr olpropcrty who huilds or nnpnvcs rhcrc.n.
<br />rnd who co mcls ior such ,njccrs wnh ! Conrlicto(s) liLTnscd purulnrrorhcContlciois t.iccns Lf,w)
<br />I n.' crcmd undd S(ri.IJ & PC lor rhnrcxvn,
<br />UaBrDf,ILlaMIrrNIi/Ul!)!
<br />DECIdBA.IION
<br />I hcrcby lffirnrundc. pcnalty of pcrjury onc otlic idlowin8 dccllr ions:
<br />-lharcdrlwillnEintli.aCcnific0rcofConsctrrroSclilnsurclorsortcnomFierion.drroidrdft,bysLr'ionlT0oollhckbor codc, ti* rhc l)crrornrNc of lhc wort forwhichlhc pclnir is issucd.
<br />lhrvc rnd *ill'nJinrrio \ork.rs co'npciurnnr insttuncc. as r.qutrcd hySc.riM 1700.frhc tr$or Chdc- i,trihc ncrronnrk.of
<br />i nNufur.c c.tricr nxl p.lic, nutrrtcr&
<br />C (i
<br />-l
<br />ccnilyth inrhe rcrlormnccoflhc 'ort lor whichrhis pcrnil h ilsucd.l \hJllnor c.rtlora ylx6.n intnym!.ncr
<br />$ N ro lf,roE suh,cd ro rhc w. .^ smpcnsrtr hwr otcrlinmin. d ignc rh0t ifI should bcc.m sutj.rl hrbc
<br />w.rk$i L\,frI)tnsari{D prolir ions .f Sc.rion l?0O .f rhc bh, Codc, I sh0il. lonhwith comtrly e ilh rhoe prolkn,ns
<br />WARNINGT Frilulc lo wurc sorkcr' co.rFnsalion c.vcnsc is !nla*tu|- ud \hall rubFcr r. unrlo)tr ro ci,nnil llcnolri.s and
<br />civil fincs up lo onc hundEn lhousand dollan (31(x).0(()). in oddilion lo rh. cod ot.ompcnillion. d!trtrscs rs providcd fu rhc
<br />si
<br />I hfl rhyrflnnrrndrr pcixlr!ol txrjurtrh r I r r li.ctr{\l dcr |miv siotr ol ( hrtr.r 9(connn.n.i',a wirh s.didr T x)) oll)ivisloD:1
<br />ol rhc llu\ncs rn Pfuri\\i{nL Codc. Md nry li.ci\c is ni trllktrcdd qaI )-.) G 1
<br />(ItrI6
<br />IAIiIBI,&IIANIENDIIIjIIiENCT
<br />I ficrcl,y annm undcr penllryolp.rjuryrhar lhsc t a on(rucri,,n hnding ogcncy for lhc pcrfoflurcc oflhc Borl lor *hi.h lhi\ r.rmi! is
<br />hsucd (scc.1097. Civ C.).
<br />AIELIIANLIIEqdAAIIAN
<br />llmbynlfinundcr pcnairy oipcrFry nnc ol rnc nnbwior dccl(nri{,ni:
<br />lxnxnirion Pc h-Asbcros Norinlation l.cdcrrl R.rulsrions(-lirlc 10. Pxn6)
<br />Rc.luncd Lcttcr.f Noriljcolion
<br />I c.difyrh, rh. Ld.rol nplhtions rcgudinB osbcstos rcmval ffc nor appliablc b rhis pn'jccr
<br />.cni,i rhd I hrvc rc.d lhisrppli.ar !lxN! inromrion iscomr. I rgre tocomlly wnh aU Cn, a.'i Counry
<br />ordinanccs md Sirrc LrNs relorin-q ro bu
<br />,bovc M'ioncd llop.ny for iNFrlion
<br />DpliMtrl o. AArnl SixDlurr
<br />SITE.WORK DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />Subf loor/VenVlnsulation
<br />Rool Sheathinq SbSY
<br />Shear Wall
<br />Framing
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./1nl. Lalh
<br />Brown Coat
<br />I\4asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req \
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />lr
<br />Wrc'l3t4?1
<br />&-n
<br />wtLNotesRemarksEtc
<br />FINAL
<br />Certilicate of Occu {^41
<br />'c a\l -
<br />I (
<br />I
<br />-r Icmileo n!melpnnl):
<br />ul heEhylurhitrirc rcti.s.nr.rivcs oil ht Cirvmd Counrv r. c.r.r unrn lnc--< r ,'\)ls t ixrr.rt u
<br />UFER Ground
<br />SLAB Floor
<br />U49/t1tt6ll$ .
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<br />I )I (t
<br />L1iJ.,',\ Nr,tr..
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