BEFORE ME, the undersigned Notary Public, duly commissioned and qualified:
PERSONALLY CAME AND APPEARED:
who declared, under oath to me, Notary, that he is a duly Registered Land Surveyor, and that in accordance with the provisions of La. R. S. 9:4820, he has made an inspection of the following described property, to wit:
That said inspection was made on , _________, at o'clock. Affiant certifies that as of that time and date no work had begun and no material had been furnished to the building site.
Registered Land Surveyor
La. License No:
SWORN TO AND SUBSCRIBED
BEFORE ME, NOTARY, THIS
___________day of ______________,201__
Notary or bar no.______________________
My commission expires:________________
For issuing guidelines on this form, see Guidelines.