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BUILDING. INSPECTOR RECORD
<br />OWNER BUII-DER DI]I-(ARATION
<br />I lEriy lllttrr utrd.. p.n0lly oI pcrjury rhat I !m crenur ln,m rhc Cotrtr.bN l-a..ic Lrw tnr rhc iollowinS rciv)n rsN 70.t15
<br />rlu\ir.$ &i ltor.\ioo C,xtr): Any Ciy r Cou.ry wh{h rcqurc\ i Fnnir ro con$fld. ollcr- iorPn'rc. {lcnx,ll,l, !r '-rrtr liy
<br />nnirrurr. I,int, ir\ (\oatud, nho i.qun.s rh.amli..nr lor \u.hlxnnn to nb a siSncd (atcmnl lhxllEor shc i\ h..i{d IUhrJnr
<br />r,) lhr nhvi\n,n( df rtr Conilrclttr \ l-iccnrcd L3w rchlptcr 9. Comnrncins $irh sc.rnrn 70(n r Divi\i'n I oi rh. Bu\irrcs lnd
<br />hni$i,,n\CoJ.rirrhsrh or\hc h crcnpr rhcrcfromrnd rhe hr\k tur rh. xlLlcd.rcnl0ri(,n AnyriolarionolSc.rnn70:ll5hyany
<br />!mlr.!d nn tr ttnnl \uhBr\ rh. rn,,]Nanr b 6 crv il tEmhy of n.r duc rl!'n tivc hufrncd dollr! M(x) |
<br />l. nr owmr .r rh. pb,rny, or my .mplor..s wirh w.Be< as $.n mb cotr{Ensl i{,n. *ill do rlr k t .!n rh itrrm n hn
<br />inrftj.i or ofiar.d for $L ( S( 7O{- Ausinc* lnd Pmfcssion! Codc Tl'e Conkrdolr Li.yn{ tf,w dN! nn .nnly ro !n o*mr or
<br />rhr pn tfry *h, t{ilt\.r inlmEr rlrm.. ul wb dq suh *r* hnmclr or h.rclf.r rhmu3h hi! or h.r own .f,plor.s.
<br />nnviJ.n rhrr ru.h iml,owrnk m r i cdd nr olk tu qL ll trftE, rtf, hrili.S nr inpmEmnt i. s! *ihh orc Fa
<br />or ronr,Elntr rtr (h rcr Build.r Bill IEE rh. h,n n ol pmvinS rhd lE or shc dn d hlild or ir{ftE th. ,turdy fr 0r puqrs or
<br />-1.
<br />arowErofrlE F ncny. smcrhsilelycnnrruiins *irt li.cosi conrrulor\ b..tre r rh. rmJd lse. ?0+{.ltrnftjs
<br />rn t\lf.srn C.xl. Th. Co.tr&ror's Li.cns. Irw dG mt aplly lo M o*rcr of pmlEny *ho huild\ or inprow! ihdstr.
<br />Jrl str' .on J.r\nn !u.hpn')L{r\ s hrConr l(t,licn\.J pu^oMr (,rh.Cor reroi. Lirnr k$)
<br />r,",. '/(e-6\ -L<
<br />I hrutt rlltm tr J.' p(Mlr) olnrrtrtomofrh. rr)lk,$ '.! dcrlmr(D!
<br />I ha* rrl *ill mi.irh i cdif(x. of conrnr io s.lf.l.ruG tu srt6 oqEns ion. .r Fvi.n for by Strrni ,7m oI rhc
<br />L,hq Ad.. for 0r trfolrlrft ofrh. *dt fd shah rtE Fmir k LiEd.
<br />-l
<br />hlE nrl will miniain worLcr' larrtnqtbn itrsrmc. f,i rntiRd by Sdr it. 17fl, of rlE trbor C.t . ftn lh. Frlolrrfu. ol
<br />rlE uqt r{n *hih rnis rEmn ir irrd M, B..Ln mmFndi,n turr. crir .rn l[ky rurl6cr G:
<br />-l
<br />$nify rhar in ilr F.ttrmN of rh. rort fi, whi.h rhir p.rmn i k<udl. I {EIl Rn c.rl'hy !n, Frsn i. rn, lMF
<br />$ .. to tralE iuq..r ro rlE xrt6'e'qENrn Lu. oa Ciliaomr. .,i .sr rh:r ir I nhuld txrom sbFr to llt
<br />*,116r .\lqEnsrhn Fovi.nn. of Sdbn 1700 ol rlr L,t( Cd.. I 1h!ll- fonh*iih o'rily wnn db{ pn'vnhN
<br />ion $tr4c n lnL*tu1 ,rl shrl $t'Fi m crrihF lo siniNl rrDrar c,n
<br />d.m3.\ ts pmt .d ror rh.ctrlil nml up t, or hudrcd rlntqrrl i. &Uirrm ro rrE on of conlEldi
<br />D.k. -to-ot -L(
<br />@gl8all(xl
<br />I h.r.l,y.firn un let Ffllly ol Frjcy th,r I d latr$j n[l.r F)l*i'n orch.t d 9l(
<br />ol
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<br />Ao(ft$.rxl PNlairB C.&. rn hy la.trE n i" flll rorft rd.fl*r
<br />trirh Slrrhn Tlxxrr or I)'1nrn, I
<br />.t€t 9
<br />g)asla!,rJllrNt ElDlNlilclN!}
<br />I hcEhy lltrm orl. FDX,6f p.rpry rh! rlEc n r 6nrtu1irn LdinS.Smy tu rhc Fnl)l1rEre of IlE hrk for \t.h rhr JEni ir
<br />niudtsa lrDT.cir c )
<br />AEII.I!;ANI.IECIJAAIP
<br />I hdr{'} lninn unds Fnrlt y ol p.tJort om or rh. ft,lk,f, irg d.rlrflr hnr
<br />Dcmhiin Pcmir( ArlE(o\ NorirEori'tr F.ncrl Rquhri{,ns rTirlc40. Pd6)
<br />-R.!uncd
<br />L.lH or fhirrdir
<br />I..n'lyrl'i rlf, lrJ.'r1,.!ulrr() \,r!rdnr!r\hn \rr x^rlJrc orr'|)|nrihlc r) rhnfroFl
<br />, (rrrvrh.i Itu\. r.id rhr\unpl( i,rl 'l!rL rhrr rhc finc inkrnurnn, n$n{r IrBrNtrd)nlfllywirh!ll('rvaRl(hunry
<br />oiilnr*li.nl Srarc liw{ rckhu rrl nrrnc\ ofrhk cnr rnd Countyr, rtrrr trIxinrlI
<br />rti{. trrnintrrlp'ottdr r,n r
<br />SITE.WOHK DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsu lation/Energy
<br />Drywall
<br />Ext.i lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Beport
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL //-8 -r 1 &cz 7
<br />Certilicate ol Occupancy
<br />Notes, Remarks, Etc,
<br />;"," (o -o\ -lt
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