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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER AUILDER DEI,CARATIoN
<br />I hcr.by rflirm und.r p.nalry or lcrjury rhar I Dh cx.npt rmm rhc Coftndon Licctrsc tiw ior rhc n,l[,wiie rcrsn (Scc.7o]1.5
<br />Busin.s 0fr1 Proli$ion Cdc): Any Cily or Coury whnh rcquircs s Fnn k, .didru.r, rl'm. rmFrovc. dcnn,lGh or rcp any
<br />in.trr.. pri{trb irs issxrtud, nko rdqun srh.ll)pli.mi trn suchFnnirto lih. li8ncd slolemnl rh ne o! she n l ic.h\.d Ntsuanr
<br />ro rhc prorisnnrs oi tlf, Conracrols Licen*d tiw lchaptcr 9, Con ftnci'rs wirh sc.lnr 7fiI) ol Divisbn I of lhc lrusnr$ rnd
<br />Prolcssion\Codc)orrharhcorshct.x.hptrhcdromddrh.ba\iLithc.llcgcdcrcnDlion.AtryviolarionofSccri.nT0:ll5hyrtry
<br />rfpli.nnrrDrrpcrmn!nbj..Nrh..pplicdutoacililpcn,hyolnorrrceth0nfivchundr&ldolld*($5u)
<br />L N .wn.r or rhc pmFnr. or m, .nployccs wirh saecs * rhct $lc coorFnsarion. will do rhc *lrl und ili id'm n nor
<br />inrcndcn or onircd ior salc (Ss 7Or4, Busincss ond Prclt$ions Code:Ihc Co.rracloir l-tctrk Ljw des nor.p/y ro in.Nner ol
<br />rhc nDncny qho noidc or iflpnB llE@n. and sls des uh soll hinrclror h.r*lror rhoulh hn or hcr own cBrl,,r.c\.
<br />pn,vided rhar srch inpro!.mnrs d hr inrc.d.d or o0er.d for slc ll lx,scvri, rh. truiklinS or imrmrenEnl is sru sirhin nm )Dr
<br />ofconDlcrtn, rh. O*ncr Brikld *illhak rh. hxrd.n.fptuvi',s rhd hcorsh.did ior buikl or iftyroE E Imp.ny for rhc lutlnE ol
<br />-1.
<br />as owncr of rhc Dmrcny. !m eicllsivcly conrtur ing wirh liccnscd contr.roN b .onnrucl lhr pojccl (SN 7Ol,r. Au\incs
<br />anJ Phrd\i,n Codc: Thc Conra.ruas Li.cnsc Law de\ nor trpply ro owncrofpron nywhobuildsortnpnntrrhcrc.tr.
<br />and wno o mcrs for such pmjccls wirh ! ContEcro(s) liccnsd puFurnr ro rhc G,nr,cttr s l-iNtr\. tjw)
<br />-l
<br />a'ncx.mpt under Sdt
<br />""'", a-q-\
<br />I h.rchJrlltrmtrnJ.r|x rhyol|[rluryo colrlrlull(iui,r!dc.ldrrnN
<br />-l
<br />hrvc ud*ill mainrain,CcnificarcorConsnr t' Srli loidrc ld woikns compctrslion. $ |)ovidcd n,$ySccrnr.]7{x)orrhc
<br />tihor C(ic, forlhc Dcrformncc oflhc *o ntr *hicn Ihc,Eirnit is islcd
<br />lhnlrr dwill hltrranrsorkc co llcn\dnn Burrirc. d\ rcqtrrcrlhyS(rion.17(DolrhclrhorCodc-nnrhcpcrton rftcol
<br />rhc work fu *l,ich rhi\ p.nnir i\ isucd My*orke^ .o'np.n\rrnnr nNUfutrc cnricr.rxl Fnicynurt !ur
<br />-l.c
<br />ifyrhar ir rhcFlloirnonccofrhe wort forwhichlii nerdn is issu.d,I shrll n.r ctrplora.y p(6on inanynEDncr
<br />$ ar ro trcoft subi.r k, rh. "1,&m L!mp.ne'io.l,ws olcaliloflrir. otrd a8rcc thd ifl \hould tEom sul,i*r ro rtr
<br />workds.omr.nsarnrnrmvi\nnsors..rio.l7(x)ofrhcbtlrcixlc.lshlll.lorrhlirhcotrrplrwirhrlx,tpft,viriotr\.
<br />WARNINC: I'nilurc ro surc sorkcrr coflrpcnsti covcrlsc i\ rilrwtuL ,nd shall {6j..1 0n cnDlo)cr ro simnral Fnrlris lnd
<br />cilil 6trcs up lo onc hutrdrcd lhousrtrd dollurs lSloO.lxXJ). in rd irt,n b I ron fl .nDtrtr{rri,r. rlrtr !cs r\ p.o!i,l.,l lar r1[
<br />Sc.rio 1076.i lhc lrtxtr Codc. inrcrcr and Jnonrcy \
<br />IECLAAAII]N
<br />I h.Bby,innnu0dcr p.nalryolpcrjury lh l anr liencd undcr fmvhioo oi Ch{rcr 9 (co!!mn ing wirh s.cr iotr ,OLU) of Divnn'n l
<br />of Ihr Businc$ lnd Fore*ioni C.d.. Nrl m, li...sc is id full tuu i cllccr
<br />Liccnsc Nuo'h.r
<br />CAXIiIXIgUONI,ENDIITG.AC.ENSI
<br />I fiercb, aafirh undcr pcnalry of ri.rjury that ln@ is a .on(rucrkt. knding ,8.my for rhc Fforrue of lhc sork lbr wli.h lhis F.nln k
<br />nsued (Se l(,?. Civ C.)
<br />ATTUIANLIEII,ABAIIIIN
<br />I rrn:ty.lt_nn undc.,.nrlty of Frjury om ol'thc iollowin8 dalararions:
<br />D.trDliion Pcnnir$ sbcsos Notificdion ltdcml Rcpuhlions (Tnb 40. Prn6)
<br />-Rcquircd
<br />Lcxcr of Nolificolion
<br />I ccnilirhrr rhc fcdcrrl rcBlhrtr,ns n8:dnr! a\trno\rc r^rlrrc tror rt,Dli.nhl.lo rhi! p'(tci
<br />l.cnifyrhar I hrvc r.d lhis upplicario. ad sl0rdhnl $c ltnvc innnmlion i\ corc.r I ald ro.onply*nh0lCilyand County
<br />o'dinJD.c\rtrJSrnrct-rs\r.l fullrlobrildfiE Nd.tnnr. rtrd hcrcby aurho,iTc rcprcscnrrriv.l.rrhis Cily Md CoDtrrr ro cnlcr ulon lhe
<br />rln,!. n{nri,nrd pmrunrn, i'sp.crioi pur
<br />Arr,li.rnl or,\xcnl SiAn lu
<br />aeA
<br />,""+-q- l3
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVlnsulation
<br />Roof Sheathinq
<br />Shear Wall /':)
<br />Framinq tll4lnlna tk l-<.J
<br />lnsulation/Energy U L
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Irilasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil
<br />FINAL tb,Jilq 1t }fi'r'.,61€.Ll -*2>//
<br />Certilicate ol Occupancy I UI
<br />Notes Remarks Etc.
<br />,,,", >. i - l[
<br />^pptisn,:
<br />I .n,l,r'\ ,ld'.s
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