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BUILDING- INSPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNElr AUtLDER DELCARATIoN
<br />I h.rchy alltn undcr pcnilr, (, l,.rjury rhd I !m cxemfl ftom rh. Conrxckns Li.cDsc Ln$ iot rhc tulbsinS rc,son (S$?011.5
<br />Ilu\inc\s !'rl frcrc\sion Codc) Atry Ciry or Counry whth t+nc\ r dmir ro .on(ruc|. alrcr, nnprovc. dcnolish or rcpan atry
<br />sflcrurc, ffirr r. irs issu.trcc. lhorcqutcsrh. rrpli. r for su.i IEflIljl ro lil. D silmd {drc rc rhai hcor shc i\ li.cnicd Pusurtrr
<br />n, rhc pmli\nrns of rlE Co Bcttr s I ic.nscd law (Chlntf 9. Comntncing *irh Sccrio. 7U)0 of Division I of rhc Rr(in.\( r
<br />ProlcsiotrrCodc)orrlurtrorshciscrcnl thcrcf.omand lhc blsh tor rhc allcBcd cxcmPlinn. Anyvi(,hri{rnofSc.ri Tlrll5$v!trv
<br />nmh.n tur a Nrmd subjccF rhc aprlicrnrt' r.ivilp.nalr!Dfnor nrncrhln livc hun{tdd.ll0s 13500)
<br />l. ns owner ofrhc lrorrnr. o ny cmpbyccs $il[ $n8cs is lhcn s,h.o'nFnsiltrlr. silldo rhc sor[ lnd rhc {n.rm i\ Nr
<br />inrendcd o! ofcrcd fr slc 1Sd.7014. Busircs lnd thfcrion\ Cnlc Thc Co.ricr.l \ l.i..n{ t-rs Jo.\ tror rPrly ro xn osJrr of
<br />rlr l1l)ttrny who hilds or i'npn,vcs rlr.d,.. o.d who docs slch w{)Il [nnsclfor hcr*_ll.r rhmug[ his or ltrr owtr cnrdo)k\.
<br />povnhd rhrr srch imnmvcnEft 4 d inrcrilcJ Dr urc(n for $h. Il h.!.v.'. rhc hrikli'B .r nrJ'mrcrm.r is {,ld sirhn onc )sr
<br />oiconDkri{,n. rhc Oens Buill.r willh{rc tlE burJcn oiFrving ltur hr d \hc did nor build or imnr)vc Ut rtuFny 6! llE purlxNoi
<br />I. $owncrofrhcrmDcny. rmcx.lusivclyconkmting sirh hccnscdconrracbrb.onNrucr rh. pn,lltl (Scc ?O'r4. Busirrc$
<br />lnd thr6si,nCodc ThccotrtactoisLiccnscl,!wd.csnoraprlyk,MoN.doInroP.nywh()htildsornnprovcsrhcrcon.
<br />atrd who . rrmdrfor such pmFcrs wirh a CunlJ(kr(s) li.c.scn pusulnl lolhcConr!.toas Liccnsc L!w)
<br />I rmcrcmfr u.d.r Sccrn
<br />}I}8SEIS:IQIIII'NIAIION
<br />DDCIA.BAIIAN
<br />Ihcrdby rlfinnu dcr Fnrlryol ncrjury onc ofrhc tulbwi'ra dcclnr.h.ns
<br />I hrvc rM rillnDinroitr r Ccnifictrrc or cun$m ro sclrlnsurc ior * orkcr' co
<br />'nFnsar
<br />io.. 0s Pmvidcd nr by sc.rion]T0Oolrne
<br />ljbor Cod., for rhc p.rlo.nuncc oflhc qork aor whicn Ue,rmir it issucd
<br />I h.vc rtrd will rMinrnin workcr! .omptnsatnf iNuramc- a\
<br />lhc rorklor*hich lhhFrnrir i! irsucd. Myworkcn conll)cnslr
<br />hy Sc.riof 17(xrolrfu Lrnltr Codc. tu lr. P.nn'r r.of
<br />i:\urrn..., r'rd r |r,li.t trtrdr.r rc
<br />I.cdilyrhd ir thc pcrforun.colrhc *ork lor wh rhis |Irrrir i\ i\\u.d. I \ht'll mr einpl,,y rny Frn)n i'i rry nErntr
<br />ifl\h.uld t(om subjccr r0 rlr
<br />conltly\rihrhc pori\ions
<br />I $hjc.r rtr cn,Iloy.' k, d i'rl P.trrlrics and
<br />)l .on,F-n\rri,nr, d.trIrgcs r\ In*idcd n, rh\
<br />(, trt,hc(nE lubjLrr rorhc wo*c compensrrn,n h{sofcrlifonrir. rnd dgt! lhJr
<br />workc^.o,rp.\xrionprovriotrsofScrion:l7lx)ofrhclnhorCodc.lshrll.l.hwirh
<br />WAnNING: Ii,ildrc n, *uc wo*cs $mpctrFrion co
<br />.i!il lincs up ro om hundnd rhousand dollarr 1slo0 r. n, rdrlirtr)d r, rhc c.{ I
<br />S..ri,nr:1076nlrhc l- lrtr tndc. $lcrci
<br />I h.rht rl1n u JcrNnrliyolpcrjuryrharIJnr
<br />DErt aEAuoN
<br />tr*lundcr|novisionolChryr.r9(.. nrcncinS$ilhSe-'rt,n7(XX)of Divnbn.]
<br />ot th. Busi',c\\ 3.d PtuftlsnrsCode. aftl rylirctr{ i\ iL, tull ilrr .lltcr
<br />CANEITqI:TONUIXDTNC.EGENIT
<br />I hcrchyrtilmu c, pcnrhyofl.rjurythd rhcrctrconstrucri,)n lcodi',! rlcNy Lr Ihc li.rfonunce ofrhcsork lirr (hichrhis Frnir is
<br />i\\ucd (S.c.109r. Ci! C )
<br />trnd.ii Addcrq
<br />-
<br />AITLICANIDECIAEAIION
<br />I trRiy anln undcr pcn{lly or p.rjuty orc ofrhc hllowins dcclarxrions:
<br />D.trk irion P$nil$Ashcstos Nolificrtn,n Rdc.{l Rcgu[tions ( filh,r0.ltn6)
<br />R0tuncd t.llcr oi Norifictrrion
<br />I ccnilyrhd I havc rc rhhapplicariondrd$riclh thcabvc itrimuri,,n s codccr llstet,confly*nhrllCilvtndCor y
<br />odiMf.csrrd Skr.luws rchri'rg ro htrr co.{ruclion. nifu'.byr horizcrq,rcsctrlariv.\olrhi\Cilyrnd(nnnlytocnrcru rrh.
<br />rh c nf,nri{trf,d tro|Enytoi inspccri
<br />,\pllicnnl o. ,tA.trl Silnnt 9n2a
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Rool Sheathinq
<br />Shear Wall A
<br />Framino (-zg -ty X,\L{t0t
<br />lnsulation/Eneroy
<br />Drywall
<br />Ext./lnt. Lalh
<br />Brown Coat
<br />l\4aso n ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL 7-17-tY x.wla
<br />Certificate ol Occupancv v
<br />Notes, Remarks, Etc
<br />L>---y
<br />-l
<br />cenilyrhd rhe rcd.ra I r.8u lat ions rc8ffdins rshcltx rcn,vxl rc no' rtPli.lhlc b rhi\ P(,jt.r
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