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BUILDTNG- iI'ISPECTOR RECORD
<br />SITE-WORK DATE ID/SIG.OWNIiI{ BUILDER DELCARATIoN
<br />I hcrcby nflnm und$ Nnrlly ol pcrjury rhrr I nr cxcnrDl lirnn rhe G)drackn' l.ic.isd ljw fd rhc lillowin8 rcasn (S( 7ol1 5 .
<br />Busincss r Proicssnr Codc) Any Ciry or (.(rnry !hi.h rcqutc\ x l.rni n' ..fstd.r. drcr. imnro\c. dcnnli\h or rcp,n niy
<br />srtu.rur.- prior ro ils issurncc, lho rcquirc\ rh. rptli.rnr f.r ru.h Frnii ro lilc i si!rcd (arcnBr rhar hc or shc is liccn{d Pursurtrr
<br />ro rtu pmvhinnr oI lhc Conrm.lo\ Liccncd l,aw (Ch+rcr 9. Connr..ing virh sccrion 70m ol Division :l ot rhc Bovtrcss trnd
<br />lDtcsrn'ns Codc)o!rharhcorshc i\.kmpr rh.r.ri(,nnDd rh.basis fM l|rilcgcdcxcnrDtion. Anylioirrion.fS..riotr70.ll.5$yany
<br />rtplicnnr ror, pcmn subjc.k lhc rlpli.n lo rcivilNnlltyolnor rnorclhln nrc hurddddolla (S50o)
<br />-l-$sosncrorlhcpmpcny.ormycnirl,)irs*irhwtrcc(r\rhcrv,tu.orl[trsrtion.trilldolhcw.tkrndrhcdndurci\
<br />{
<br />i'{cnlcd or.[cr.dtu$lc(Sc.7(!-1.liu{incslndPrdcsionsC.nc]'lhcContacttrsLicc.cLrwdocsnorrPplyn, oakrof
<br />rhc tmFny *ho hilds.r in{l()rcr rh.Fr. rElsho dtEs ruch wolk hnnrlr or hc^clf.r rhn)ush his or h.r o*n cnyhy.c\,
<br />pn,lidcd rhlr such i'n|nr.mr(dckn irrctrrlcd or oilcr.d foi \alc ll. howcvc. rhc tuiklin8 or imnmvcmm it *rd wirh$ onc ,qn
<br />ol co'ntLri,, . rtf, Own.r Buikh will havc rhc hordco ol trcinp thar hc or \hc dil frr t[ikl or itpnrk rh. pruthy ntr l$ pu4xrs .r
<br />l. ,\ owtrq ol rh. rolcny. nn cxctusn ely conrEcrins wirh licen\cd contrtB h onifld rtE rn,j.rt ( Sc. ?(!8. BL\inc\ i
<br />rnd PmicsbnCodc:ThcContncrr'sLicchcLiudocsnornpplyt'!ro+Tcrorpi(,r,c yqh. buildsor irnProv$ lhcrcon.
<br />lnn $ho cotrrrrcrr for skh pnrFk wirh a G rrcrinIltcnrdluBu.ntr.rhcGn racffsl,tcnscbt)
<br />-l
<br />x crcnrnl ! cr sr.ri0n
<br />Dale: Osn.r
<br />\toRI<ERS' COIIIPFNSATI{rN
<br />DLCLAAAI]O!
<br />I hcrcbyrllirnr!n.lcrpcn ryolncridryon.ofrhcfolk,$i'ig.lcclrrii(trs:
<br />lhrvcuxlwillmrinrinrCcdir,.iicolC.n\ctrrhSclaln\urcfor$oltcrrcoDtxtrri,nr.r\rii,vidcdr(nbySBrion.l?lx)ofrhc
<br />l.rhr (inlc. f{r rhc pcrnmuncc ofrhc sork 6r *hi.h lh. pcnnir is is{EJ
<br />I hnvc and will nriflair workcr{ compc.srtion in{trnncc. (s rcqtrircdh)Sc.rim.17(D.frh.t]lnrahdc-iorrhcPc tr'mtu.ol'
<br />rhc work itr*hkh rhisrcnnil is nnrcn Mysorkcs c.mpctrrtrrk,n in\urancccrfttr md Brli.ytrun$crtrc
<br />nallo ,tat (
<br />'TtqqqtozA .z-(Q -{?
<br />l.crrilyrhd inth. DcnnnNrdc otrhc worI lbr *hi(hrhi\ prrmir i\ istrcrl.I\hrlltrol cnr oyany Pcr{nr inrnyntnicr
<br />v,r\hh.c.n,c{$jccrhrh.w.rkcr((nnpctr\rrrotrhwcof(lilitntrir.odil3Eclhdiflsh.uldh-corc$blrtrk,rlE
<br />trork.^.orlr$noirrovi(ion\olScoion.lTtx).Irhcli$.r(ndc.lshnll.fonht(hconltlyuirhrhotn(ri\i.ns
<br />WARNTN(;: F ilurc ro sccufr sortcrs .onu-h ii)n d)vcn'sc is uliwlil. rtrd \hrll \ul'Jccr an rnd.)tr tu lrnniDl Pcnrlrtr rnd
<br />civil ndr\!pk,otrchuidr.drh.uMtidollrr\($l(X1.(Il0).inrddiri,nbihc.on.f.onrrcnsxrk.drtuscst\providcJf{trh
<br />S.crn,n.1076.frh. trhtr Ctxlc, ir crc{ drnonrcy s lL{s
<br />r,"' t ZO'IA ^ro,^*,.Y[ZHU(lx)lL(aNI&TqQtr
<br />DEIIABAI]ON
<br />I tEmhy afllrm unds lrnolrroltcriury lhd I !'n lieosd lndcr rnvi\i.i orChaPrs 9 (omnErcins trirh Scdi.n 70Oo) orDilRi.n l
<br />or rhc Bu\iicss,nd ProLsmns Codc..nd my llccnsc h in fullnxcc md eflicl
<br />Liccnsccr.ss-lC 3q I .loo-y'.8q I
<br />-a/Q-lE .*"*",.& 1Z-
<br />g)NiIAICUONIDNDINS.AGENII
<br />I hcrcl,y ltrtn uider pcn,lryorFrjury rhd rhcrc h a.onstfl.lrn lcndir8 aScNy fnr rhc pcrlorron.. orlh. wo.k for rhich lhis P.n.ir n
<br />issucd 1Sc..309?. Civ C.).
<br />aP.tucANtllltA&rrll)!
<br />I h.n:hy ultlm uid$ tl.ntrlry ol !.rjury onc oarh. tolloqins dcclaraln,ns:
<br />Dcmolirion Pcrmirs Asbc\ros Notia.arbn FcdcralRcgxl0rions (Till. Lro. Prn6)
<br />-Rcqutcd
<br />l-c crof Norifi cdri,'
<br />l..nifyrhdr rhc fcdftdlrcSulrrionsEgardir8 asbe(os rcnx,vllm mr ap i.abk k' rhh Poicd
<br />Icdirt rhar I h*r md this trlplcrli.r inl dore rhlt rhc ltx,vc inr'o ar id1 i( ..n.tr. I rsN ro $rqrly wirh all Ciry and (-oDtrry
<br />ordinrn.c\ rnd srar. bqs rclritrt ro buildins con(ruclion. nlld hcrcby$lhtri.. rcpr.$ntaln$ olthis Cilynnd Colnry ro..r.r uBn' rht
<br />xhu\c nf,trritx'ctl Dn,mn! ri,r in\m!rn,n nurm\c\
<br />n-,"-,*n"*,.*,",.* v< $:!V4 {f
<br />,"-r**^",rnt,,U,( ][-f/'
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Subf loor/Vent/lnsulation ,-\
<br />Rool Sheathinq 7€6,ta /4/.'rc*oj3!-)
<br />Shear Wall
<br />Framino
<br />Insu lation/Energy
<br />Drywall
<br />Ex1./lnt. Lath
<br />Brown Coat
<br />It/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />Gt\
<br />FINAL B-q.G,.;r
<br />J<'r,.,
<br />"A--.,Certificate of Occupancy
<br />Notes, Remarks Etc.
<br />-,
<br />COMMENTS
<br />Set Backs
<br />UFER Ground
<br />l1!1.'
<br />^J.l',..
<br />- -^,,,'A Zo'17
<br />tt
<br />I
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