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BU LDING- INSPECTOR BECORD
<br />SITE-WORK 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 Sheathinq 7At6tx TNLA$ra
<br />Shear Wall
<br />Framing
<br />lnsu latio n/E ne rg y
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />lVlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />FINAL *zlc /lb aJ</
<br />Certif icate ot Occu cyan
<br />Notes, Remarks, Etc.
<br />OWNER BUILDDR DELCARATION
<br />I hcrcby aflnnr !.dcr Ftrilly of pcrjury thd I d cxcmu rbm thc ctnbacroF LiccNc Law ror rlr rollowirB r.rhn (Scc.703l 5
<br />Busincss aid Prcfcsion Cod.): Any Ciry or Co!trry shich rcqutcs ( pc.mir io c.n\rdcr. alrcr, inl)n)vc, d.dni\h 'tr rcFn In,
<br />srructurc. nrir ro its ksuanc.. rko requt s lh. atDlic, nr such frr.ir lo lilc r siBmd slalcmnt Ih,' h.or snc k liccnsd purunnl
<br />ro rhc ptuvisbns orlh. Conr!.rois Liccn\ed ljw (('hqrrer 9. GnmcncinE wnh Scdn,n 7{Xx) or Di{kion I olrlc ausin.ss a.d
<br />Pmfcsions Codc) or rhd hcorshc G cxcmpr rh.r.ftum rid rhc bd\is forrhr rlLtcn.xcmpri.n. An, violrrionolScclbn?031.5 byrny
<br />applicinl{or!F.nnrsubrcchlh.0lpli.oDllo.civilpcnaxyotnornDrclhrtrfirchuMrcddolla6(SsUJ).
<br />L ns owtrcrofrh.!m!.ny.or rycnrthrrtcswnh{rgr\,\rh.irqrcdnnpctr\nnnr.*illdorh(wor[rdr)f{turucnior
<br />inrcnd.t or olttrcd rbr eic {Sa 7044. Busircs and Profc$nns C()dc: Thc co.rr0crois Liccnsc Llw docs nol amly ro atr o$rcr ol
<br />rhc pnf'.ny *ho bnild\ or iqmvcs rh.c,n. and who dcs such work hid\elior hcrelior rh!'!gh nt or hcr otn dmpk,t.cs.
<br />rovidcd lhrr su.h intmrvcmic M inrcrxLi or ofierud {ir \ah ll. lx,eB. rhc 6uildin! or inipmvcdnr is v)ld wirhin .ic ycr
<br />ofcoDDkrnn. rlr Owncr Buildd *illhnv. rhc hu'dcn ollovilg rhor hc ii. lhc i]iJ rn tuikl or i,npror rhc pn)pcny ior ric purp{of
<br />-l
<br />mrcxcnrfl undcr S$l
<br />ORncr:
<br />lo.BKE&tloutlNsara!
<br />llt ct AB^ua!
<br />I hcrcb, ntnrB hd.r pcnrlry ot ri.rjury on. oithe follosir8 d(laraliona
<br />I hvc,rxlwill roiol3ir ! Ccnificarc of Conscnr to Sclllnsurc for wo slconlncnsltion.6 providcd tu by Sdion :17(x) ol rhc
<br />Ijtir Codc,lorthe pcriornuNc ollhc rc.t lor which lhc pcnn ni\sucd
<br />rhc trork lrtr trlrichrhi\ pcnnir i\ i\\ucd Myso c^ conrp.NrrnD nxurimccrmcr rDJ lx,li.ynun,h..rc
<br />c,"i..i 3G(2.- FwtJ9
<br />?-? 16a *..a'z/tf
<br />I ccnilyrhor in lhc l).rlonluncc ollnc wort jor whicn rhG pcnlir h hsucd. I shrllnor cnploy rny rr6on in any mrnncr
<br />sr isro bc.orm sublc.r ro rhc sorkcN conr|ftreliun lrwsofcnlifoii , nnd lBlcc rh rf, should hcconE subirl lorlE
<br />sorkca.onEtrs.rionpDvnionsolScclionl7(x)oflh.htsrCodc,Isholl.Ionhwithcomplywilhrhorprovnions.
<br />WARNINC Frilure r. su. workcr(.onDcnsd!.n.urraec i\ utrlnwtul. Md shall subjccl ,,r cnDloycr ro lriDinal Fn(lrics lnd
<br />.ivrl lrr\ ut ki ok hundic rh.u\1trd d.llrs 11100.{ltn), ii rddir b rhc.. or.omFNa'ion. d!,M8.s as [ovidcd rbr thc
<br />scdtr u)76of r][l-rttrti ..nncr.nx rr!tr (r'\
<br />",", -z/e-/t-t'.zL
<br />ITECI.dAAIIQN
<br />I hcrchylmrm undc, p.nshrotFcrjury thlr I om liccn*{ unds prnvhion.fCh{rcr 9(.onaEncing wirh scchn ruD) ofDivision I
<br />oa rh. Ausincss and Profesions Codc, ud my li.ensc is in full lorc nl calccr '
<br />fitzod /,,,*.*ii 11r
<br />coNsrSr]g&NrlllracltiENcr
<br />I hcEby ffi.rn undcr Fniky oi !.rjury rh.t lhcrc is a mnnrudirn hndirB o8cncy for lhc pcdorronce ollhc *ork tu which rhis F.dir is
<br />is\ncd (Scc.1097, Civ C ).
<br />ATTUCANLIECIdM.IPN
<br />I hcrcby dnnn undcr pcMxt orpfjuryonc ol rhc roln,win! dcclrartns:
<br />D.nrlirron P.rmn+Asb.sos Norifi..rnn F.d.rrl R.guhions lTirl..10, Prd6)
<br />-Rcqutcd
<br />hllcr ol Norifi carion
<br />I ccnifyrhrrrh.lrd.nlr.guhrnnN rdCxdiDg r\hc{o\ r.trn,vrl rre mr xpplieabl. k, rh'\ ,K!c.r
<br />orditun.cs ard Srdic Ltrws tuLrirc building.un(ru.rn,.. rrl hcrc$y,udorizc rcpc*n'alivcs olrhis Cilyand Counry lo cnrcr DE,nrhc
<br />xl,old nrdk, ulf'o|r.d) ntr
<br />,lt)0liLnnl or,\tMlSiEDit t1_
<br />,)(5 ?4!{
<br />I
<br />DATE
<br />L asosncr.frhc pml].nr.,nrcrclu\ivclrconrracrins wirh liccn{n conrEcn'F rn con(tud rh. p(,jr.r (s( 70{4, Busiri.\\
<br />r Lnnls\ir Codc: Thc Coft..r.fr Li.on\c L.* doc\ ioi rpply t, rnowncr olprcp.nl $l.i buildr or inpbvcs rhcrcor.
<br />rnd who s,nimcrsnn \uch pmrccrs wirh rCo nclo(tlic.n\cd pur\urtrr lotheConrrncktr s l-iccns Lla)
<br />,a-oz*
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