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BUILDING. INSPECTOR RECORD <br />SITE.WORK DATE ID/SIG.COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subfloor/VenUl nsulation <br />Roof Sheathing <br />Shear Wall <br />Framing .///2// f /4.ilr?r>_e6?- <br />lnsulation/Energy <br />Drpvall <br />Exl./lnt. Lath <br />Brown Coat <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Engineer Final Report <br />FINAL //h/E Oncry-t0- <br />Certificate of Occu pancy <br />Notes, Remarks, Etc <br />OWNER AUILDER I'ELCARATION <br />I ha.t, ,Irm ur(b Fdty ol Fjut $r I m odti ton rh. (o r.1m l-ic.B ljw f.r lh. followi4 r@rn (Se70.1I5 <br />Itui.d i,n Profsirn Cod.) Ary CU or Coud) utict rotun6 ! Fni ro or6tNcl. .h., mFovq ddnolisn o. EF! My' <br />.tuclua rbr ro ir3 isuei .!. r.qiriE ilE epltd foi Bh Fmn ro fik. siSn d mt thd IE or ltE n lE6B.d plsud'l <br />lo rh. rovBio6 ol rlE conr.crd! Lien(d L,v (ch.p{6 c. comdinr [nh $dnn ?000 ol Dvirirn ] ofrh. Burirc &d <br />ft.ltB'ont Cod.) r rhll hc or !h. i! qdpr lhd.too .nd llE b.a tu rh. rlle.d .ranFion Art rhhthnotsdion 7011J by rry <br />!ppli.$t aor . Fnit Nbjda lh. +pl,.dr ro . civ il p.Mhy ol mr mrc llu fivc lundr.d &rU6 {1500) <br />-1. <br />s o*c olrlr p.oFrl, d m) anpbta trirh $!s6 d rhn $L (mr6srio.. \illdo !h. worl e'd dt rdft i mr <br />inrs'd.d or offa.d am rL (S(.70r.1. tt6iB ud PmfdioB Co&: Th. codrrdd r Lk.e L!$ 66 ml .rply lo D ohr ol <br />rhc riorqry *ho &ildro. inlFlr6llEoa.rn wb dE$tw tiN.l[., haelf or rlNsh hB d lE ou dplorB, <br />For iH rhn qch ihF!!ffir ft ,or illldrLd or o0i,rd fo, $L l[ hd*6d. tlE txildlB ( lrFrvdE{ i! ild wnhD oE yd <br />ofonplrho. E Os€ Boilta tr1n h.E 0E hrddr of F!r{U rht h. or sh. dil fr, hrild or imp.ltr lh. Frur* tur tlE F,tE of <br />l. s oMd oarh. <br />'j.oFlr, <br />m cxcluiv.l, conrr6.1i,* wnh [c.c.d (oiralm ro ..tu tE prrF (Sc. 7O,,1, l\u!B <br />,.d Anr*.n Codc: I1l. ( onlrlcroi r LE.d. l-!w dos ml rpplt to o of,n6 ol prop.n) tr'ho bsil& or irpror6 l[6F( <br />.nd rlh onrr&1r rtr $d F.id!sirh r Conldo(s) licd.d puButrt tolh. ( ontldoisl-i.@ bs) <br />I mcrh.{ uffl6 Scr.I .B &PC forlhis@n <br />Drt.: Ornr: <br />$Ir8Ii!8ES!TUTENAJ:I0.U <br />DECI.AiAIIA! <br />I ha.5y.mm u.d.. p.m[, ofFjuryorcollh. folkrsll'3 &rldiont <br />I hr\. rd will mint.b r Cdifrtrc orCongr to S.lf-lBUr foi Mrl(d. 6nlpa4nll\ s F.virl.rl aor b] Sqtion l?00 of lL <br />trhor Cde .tr rlE Ftnm o f th. "o for $tih rh. Fhn i! is$.d. <br />I h.rc.nd willnaintlin workdr' comp.Mtion iBuM.. s r.quiEd hqSdio.l70Oof rlE llh.r Codc, f.r lh. psfomM. of <br />rh. $orl lor $hth rhi. Fmn n is.d My uorkda comFMion 6u@...rd ai F)lrl tumb.r r.: <br />-l.drit <br />rhd in llE Fforum. of rh. wort for which thir Fmil is irsu.d. I sl'.ll nol .nploy oy F$tr io ey ltl.llM <br />F a ro b.ar st al ro lh. *0*6 on46lrbn U*r of ( difonu. d'd rsc rhd if I rhould t8om. lublEl to lh. <br />sort6' onFslrion F!rohB ols<(ion l70o ofrlE uh, codc I .lull. ffih$hh @ry,ry wnh rho* p,ovnio6 <br />\iARNINC Faitu. to s@ worla .omFliio. ev.ng. ii lnldful rtd sldl $t'i.rl e dpbls ro mirsl FEkE od <br />cnrl nn6 r! ro oc hond rhousd doll6 (t100,00o). in.ddnion lo lh. cor of cooFMrion. drr86 6 F.tii<d for th. <br />scrion 1076 oftlE ltbor code inr6.3 .rd lnorEy r 16. <br />ITCEMIIIIOAIIACIIIalEt.a8allq! <br />I ha.bylrlmu la Fr.h) o t pdjury lha ! M l'@r.d lndd Forrhn ol ()Dt rd e (mnm6.ins wnh S.di.n 7(roll) of Diri.iln I <br />of rh. Bdilld.ar Pml6bB Cod., md ny la@ 6 h tutl rnrft En.tld <br />l-icGcCle:- <br />g)aslalicllo!..ullultilcEdq <br />I hchy .,fm unda Feliy oa Fjo,y thd rhd. ir . tudM.. tddii8 .sor for llE Ff.tua of rhc sorl lor *iich lhE tonn G <br />6sucd (s* 1007. ci! c) <br />AIIIICATLDECIdIAIIA! <br />I hdrby.&!i unt s Ft x) of Fj!,, oG 6l E follo*ine delalbE: <br />I).tuh hn Pdir+Artdd I'lotifr.lion F.dc.l Rcsubr io6 (Ii! r. 40, Pd6) <br />-Rcquid <br />ltfl6 o, I.lori6.nri <br />- <br />I cdift rhd rlE t ndd rqruLrioB rqldmr 6tdor rmot al Ec ndr <br />-l <br />csrity llEr I ha. rdd Ihis rpplic.ri.n lrl n,r. lhd {r ,ho\. infdldid <br />!d Cod!, ro ar. qm dE <br />ot -7t' F <br />.rd'nan.6 dd Srd. I $ i Eldin! r. <br />.bor. morFftn prcpd) lor in r..1 <br />:'\p"licrnl or AE0tSitnrlur.I tL/ & <br />I <br />Flood Zone Certif.