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BUILDING. INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcrcby trffin undcr pcnrlly (,f rErjury lhd I onr chmnr lronr rhc O)ntr.r.rJ Li..n$ t2w ror rhc bllowi.S rca$n (S(.?O.ll 5
<br />Bu\inc$ ond Protc$bn C.xlc): An! Ciry.r Grnr, which rcquid\ , luni io consld.t. 0llc.. imtrovc, dcmlhh or rupan lny
<br />{flcrud, pnorn, ik i\\urncc. alqJ n4un.\ th. llflican| tur \uch ncnnt ro filc 0 si8rEd n0tcnEnl lhal hcor shc n li..i[d pu^urir
<br />lo lhe lovkions oi the Conrracroi\ Ijccnrd Iiw (Chaplcr 9. Conmcncin8 {irh S..rion 7fllo or Division 3 oflhc Businc$.nd
<br />Pmfc$ionsCodc)orrhntlrorshciscr.mtrrh&cfmnandrh.bd\ilforlhcalkscdcxcmprion.AnlviolllionofS.crkn?0.ll5byrny
<br />rprlic.trrl'or 0 Frnn subjcchlhc {ff,|i.!nl k, acivilpcnrltyoinot mnrc rlrtr liv. hundrcdd.llrs (Ss(xr.
<br />L as owmr or rlE phrcny. ornrtcnrtlorcs wiih wagcs 0s lhcir snccompcn ion.willdolhe wort !d rh. nmrm i{ mr
<br />intcndcd or orlcrcd lor slc (Sa.7014. Eusincs ond Ptufc$ions Code: Tnc ConrDcld s Lic.n\c ljq docs nor 4ply to on o$ncrol
<br />rhc pmpcn, rho buikls or in{,m!cs rhcfr)n, ud sk) dffs skh sort himscllor hcs.lfor thou8h his or hcr ownc'nploy.cr.
<br />,nvidcd rhrl $rh irnti!rcNrh!arn inrc cd or otlcE{ fir slc I I howcrcr. rh. hiildir8 or irnpnvcmnr i\ {nd wirhin unc JU
<br />olcomphriotr. rlE Oqftr auiks srllhrvc rhc htr&n.fpmviu rhlr hc or shc dil mr tuild or inlmk dr pmp.iy aor ih. I rlx)e ol
<br />-1.
<br />ns o*rcr .l r hc pm|xny. !m crclNilcly conrrrir8 snh liccnsd c.nr6cro6 ro conndcr rhe prt,j..r (sc 7G14. Buqrcss
<br />nnd Pn,fs\ir Codc: Thc Contmkx s Liccnsc Lrw dors nor rnrl, k, rn osncr ufntupcriy who builds or imor.us rhcrcoo.
<br />rnd who.onrnctslot$chpmjccrr*nhooorrlcrtrls)liccnsdpunulnrhihcC.nhrrtr\Lk.n$tiw).
<br />-l
<br />!m cicmpr undcr se.'li{)B & l'(' lnr rlrr\ rri!trr.
<br />Dale Orner:
<br />wonxFRs' coltltFNSATI(;N
<br />aEcl.aSarlo!
<br />I hcrchyofir uNlcr pcnalryolpc.,u!yo.c ofrhc rollowins dalnrarnnr
<br />Ihruidwilln inroinaCcnifi.rcofc{,nrnrbSclfltrsurcturuorkc^..nr.n{ri(nr-NpolidcdlorhyScrri(r.17(xIofrlr
<br />l-ltxtr C{r,lc- ir lhc ncrfonuncc ofrhesork lnrRhichrhc |r(rmir i\ i\{,cil
<br />I h.\r rnd s,lltuinrrin workcrs.onrpctr\arion iNunn.., a{ rquircd h} Sccliu]Tmofrhc lrl'orC(d.. lorrhclctlor.unccol
<br />hrtr.r[htrsh,3
<br />retr ('a 0^
<br />l.cnny thnr in thc pcrioriMncc oirhc *ork lnr $hnh lhn Fnnil n issu.,l. I rhrll tr.r .nph)j",try pcnotr irr rtry mrnrcr
<br />v, r\ k, hccorr subjccr t,rhc workcs conrr.nsiri(,r lr*s ol Crl,lnnrir rtrd rgrcrlx ill \houkll'ccotrE \uhjccrt'rl[
<br />worlcn compcNarion prevision\ ofSdn,n.lT(X).frhc Irhr Cod..lshsll. fodhe irh comply {ith rhoc pmvtion\
<br />W,{RNINC: frilu'r ro {ruo rorkcrs ..nlcnsdrion..rcrugc '\ utrl.rlirl. rtrd \hnll slhjc.l rn e'npbycr t, dimiml ltMlras trd
<br />.,vil finc\ ut to otrc hundrcd rhous.Dd dollin (SlU),(xXr. tr dddirion k' rhc.o{ ofcompcnsnrion. drm Ars rs ln,{dcd for rhc
<br />sftri{ .1076 of rhc ljb. C-odc, imcrcs -\*
<br />ADpli. l XL\ torw /tc'c'het"
<br />Dlrcl ARA rlON
<br />I hcrhylillrm unJc, l}cnllr, ofpcrjurr rhar I a'n liccn\.J undc! nrovi\i,,n .l Chpru 9l.rnnmn.itr8 wirh S(rion ?{xD).fDiri\nr l
<br />or lhc Busirrs{nnd Polcrsi{trNC.dc. md nryliccn\c is i'r lirll rirc. r,rlcl{i.r
<br />/02070tl*",
<br />I h.rcby nf,l.n !nd.r F.trhy.lFcrjury rhat lhc.c h i sn(tu.riotr lcndirg,scrcy lor lhc Deliormnc. oirhc woik fot wni.hrhh pcrmn i\
<br />ksucd (sN 1097, Civ. C.)
<br />AIILI$NLIIEIIIAAIION
<br />I hsrbydlrflunder pcnalry ofpcijxry.nc of rhd latlo*ine dc.hrarn \:
<br />Drnn'lirion Pcrnrirr A\l,csos Norific ion F.dc.rl R.Auhrion\ (Tirld 40. Prn6)
<br />I{.qtri'rJ l.rtTol Norillcrri,
<br />I ccnilyrhnr Ihc fcdcrrl rcsuhrionr rcsudin8 a\hc{os rcrmvil rr. nor trpplica}'lc h rhN pmjcd
<br />-l,cnilrrh.(lhJ\crc'.drhhapnli,'rr'en,91+r.rhrrhrbhi\.'1r,-mir,,ni.(
<br />nc\r l.'8r'.!on'Il
<br />,rdrnrncc\!ndsidrcljq'rbr'nciu)uiLlri,,, ddirn ar hc'chyJurtr',r r.Fc{nrJrtrcs.lrhr (i
<br />Jho\c trf,n,tr{n rnr"n} tn l,'nl ^I'd, rn 4-t-U
<br />^pDri.onr
<br />or^Emr siEtrerum: L!. v v- - - D'r.
<br />ly tr irh rllCiryrmiCounry
<br />rynnd (outrry ro cnr.r uBnr rlr
<br />l)rnnil&nr.lDrinlr:+il 2a\
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVl nsu lation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />ln sulation/Energy
<br />D rywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />E
<br />FINAL 7.to.t I ':*spc .€2
<br />Certif icate of Occupancy
<br />Notes, Remarks , EtC.
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