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SITE.WORK tD/stG.COMMENTS OWNER BUII,T'ER DF:LCARATION <br />I hcrcby rtlrm undcr p.nalty ol rcrjury lh.l I m.xcmfl rtun rhc annrrd,trr l-k.nsc bw lor lh. lollowmS rc,son (scc.?ojl i <br />Businc$ i Pdt$ion Codc): Any Ciry or County whi.h rcquircs . FrDir t,, .otr(n,cl. lller. iq'!olc. dcmolish or rnair any <br />dn'cttrE. prin r{ ils nsumcc. lho rcquircs rhc.! i.nr hrsu.h lEnnir ro filc! sienql srarcmnr rhar hcor sh. n [c.n{d pursudr <br />lo rhc pn,vi(rns of rlf, Cdnta(!tr's Li.c.ed llw (Chnfl.r 9. Conmtuiie w h Scct,on '70tU ol Divnion I ot lltr Busincss arii <br />Pn)lcsbns Cqlc) or rh lE or shc r crcmd thcrcrmm md rhc brnr rr, rhc rllegcd crcmpti r. Any viohtn'n or Selhn 103 L5 by y <br />apfhcanr Lr r Frhir srhr.cB rh. rorlidd n, acivrlpcnllryoinolnrcrhrn rivc htrnJreJ dollais($500) <br />-I, <br />,s owner or rh. polcny. rtr hy cn{'[,rccs wirh *!ecs rs rhct $k .ompcnslri,'n. will Jo rhe work !n1 rh. (nde s n.r <br />Ercfll.d or ott.rJ lrtr {L (Sr 7l}1]l, aurn $ dnd Prcf.*n,ns Culc: -thc Contrrln-! Li.cnsc Laq doc! nDr ,flrly kJ er .wn( ol <br />rlf, p^)p.dy who ln'ilds u imprrrs rhcB'r,,uni wlh d{\ nrh kr* hiD(clt fi hcn.lfo, thoulh his or hcr owrcmnloyccs. <br />on,vkl.rl rh.r nEI ihpn,vcftnrs d ior inrc LJ or o,tircJ ii'r \rlc ll tx,wc\cr. rhc 6ui[nng or impn]vcr ir v'U wiihin nc r.tr <br />.l rcmtldion. rhc Owncr BuiUcr willhrvc rl[ hunb.olF'vir! rh.rh.or dr drl nolhul or impmvc rhc l'fi'oq1y lnr rhc Nqi,c ol <br />L isdwncr Irhcpr)p.rly an cxclNivcly contdog snh h.n\cd c.tri nd$ n, .! nN(ruLr rhc ltr.ic.r(Sc. 1H.1. BNm$ <br />unllhlr$inCod.:lhc(i,rr.ttr\l-iccnscl-x*ilocsnoii|]!lyr)rtrown.rolpnncdyq[ohu'lJsorrnnn,v.srh.r.on. <br />!n'l who .oDrm.rrlnr{'.hontccrsw hrCdnr&htr(r)lrcn\cJ Nusorh.(nn(i.r,trsl-cnn lrs) <br />I mc(cmnr un,lcr SLU <br />lraatrESs:colt8[xrallaN <br />DECLARATTON <br />I ncrcby alrnmunder I'cmlty ot pcrjury onc ol thc ltLbwinS dR..ldarionil <br />I hrvc ! lwrll mrinl. aCcniicrlcofConscnr to Sclf-!.rurc n)r worko a .\nnFtrq..n. ds Frvid.d litr6ySeli.tr l?t{,oilhc <br />ljl!)r C*lc. ld llrc p.rrormanc. of rhc work inr Rhich rh. I)fr n nru.d <br />-l <br />h!rc rnJ will m.inlain worteG' comp.nsil i,u inqmn.c. !\ rcqurel hy Sc.l Dn .l?00 oi rhc lnhor Oxlc, ti,r rhc l}crri'm rcol <br />rhc *or[ lnr whah lhirlrcmil is issu.'l My wolkcr' (o,l1lEtrsrtotr nsunnec.irEr ann Oni.ynumbcruc:lQn V\/Vth.l <br />I..nrlirh r rnrhcFrfo ndn..ofrhc work lar wh(h rh,t pL'nr i\,.\ucJ.I sh l nor .mtloy ..y tcr\on in lny nrmnc, <br />\i ns b h.co tc ruhjcct t, rlt kxkcr .{mpcn!rri,'n hws ol Calitnm'r. aft]a!rcc (hrr il I nx,uu h..om $htrr brh. <br />wrkcn.on{.nsari r}hv^ons .f Sccnon :l7U) ol rltr t-.hr clrlc, l \hrll n'nhwlh .on[ly q irh rh)r tx,vrons <br />NARNINI]: Failurc l{, cutrrc Rlrkcr'conpcnslliu covc.isc i( nnla*h'1. u(l shlll sulrJcut !n cmpl,,ycr lo .nmhrl Fulrieund <br />0v'l lines up !) one hu rcLl rhotrsinJ dollrr (Sl0(,.tuo). rn ail frln n, rhc .o( ol .ompcnsrri,,n. drmascs as pn,vidcd lnr ihc <br />,aI tA lb'/v\ <br />I hcrcby afinmunJ$ fcmly l Frjurylhar I dm )i.u*d undo fovFn)n df Chrrrd 9(conm.ncnrS qirhS.ction ?0m)ofDivNoi I <br />ot rhc Bu{tr.sr /trJ Pnncsri(ffCodr, rhd nry lie.n{ i\ in lnll tu(r r*l cilccr <br />oto n...(Ntrn., . 4arv4? <br />..*.".*( v tvlNtt 9014P- <br />CONSTRUCTION LENDIN(; AGENCI <br />I hctohyallir trtuld ltialry dl prJtry rh.r rlff i\ a con{trrion hnJing a!.ncy tr rh. l.rlirne c. ofrh. qork n{ phieh rhrs l.rmnr ii <br />rnr.J (S(. 1097, C,r C ) <br />knd.r'i A,liE( _ <br /> IlLIt NlDEsttBltrllr! <br />I lNt$y dl'rn un'lcr I).nilry oI0crjtrry on. ol rhc t,'lk'w'n! J..lrrr(u,s: <br />l)cm)liri(r Pcrmirs rh.sr.s Noliri.rrion l:cJcml Rc-euhriorr rl ilc r0. P{r6) <br />_R.q0md Ix(d ol Norilidton <br />l.cnilyrh rnc rcJcr.l r.euhrins rgddins nsbcror rcn$vxlnrc.or rrtlkihk r) th,s |,n,irt. <br />$F..r, 't, , t*.-,, ,n^ annl'rarion aBl n,rc r6ar rhc fi,K 'lrqnEilnr i,.oB1. r rsrm k,.ompry w h arr c y sBr (butrr! <br />o,dn,x (.\ rnJ srrr( 1_rw\ r.Lrr g r) hu,u,ns r.r.\crdnr\ ol rhis C'ryrDd CounrJ r) cnrcr ut,n rlr <br />ilxr. nrfl k,rll p'.p.ny Irn'nsp..rk'! p <br />,\ppln.nr or A,l.nr siEnrrr <br />Set Backs <br />Formsi Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVlnsulation <br />Roof Sheathing <br />Shear Wall <br />Framing <br />lns u lation/ En erg y <br />Drywall <br />Ext./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 />Flood Zone Certif . <br />FINAL rlNlzl Dffnt]d .# y7 <br />Certilicate ol Occupancy fr <br />Notes, Remarks, Etc. <br />-+ <br />BUILDING- INSPECTOR RECORD <br />DATE <br />lhlc <br />{tltl-a <br />,,"," r.tltr/Zo