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SITE-WORK DATE tD/slG.COMMENTS OlVNER 6UILDER DEI,CARATION
<br />I hcmby rlrtrm undcr lcnalry ot Frjury rhar I m cxcrfl !n)8 rh. ConkidDN Li.cn* liw rr, rhc lollowiry tasn 1s(.7011.5
<br />ausin.s anl Pn,tsn$ Cdlc): Any Ciry or C.unr, which Eqnncs a Fmir t, c.n{tuci. dlcr. impn'lc. d.mol$h or rcpat anv
<br />srru.ntrc. pior r) ir\ N{r.ncc, rko rcquncs rhc apPlicr.r rorrurh P.nnil I' lilc, siln J slalcmtrr rhrr hcot sh. is lienscd NRUdI
<br />b rhc p$vsions ol ll* Co.ka.di Li4nscd L.q (ChaPrcr 9, Connrncine *irh Scction 7000 ofDivtn,n -r dr rh' Rn(incs! 'n'l
<br />Pnrtsn,ns O,J.) .r rbsr rk or shc is cxcnpr rhd.tion drl lh. bssis lirr rhc aue8.d cxcmllion. Any vn dionorscclion ?011.5 bvanv
<br />apphdnr tD. a I'cn.ir subjels rhc aml,canr!, rcrviltcnilryolnot moorhd livc hunlrcrl Jollxr\ (5500).
<br />l, ,\ owRr of rh. poJrny, or my cmplorcc\ qirh wrlcs as lhen $k .omfnsarhn, qill Jo Ih. eqk d rh. dnEfur n n
<br />Dr.ftlai or oficr.d n)r slh (Scc 7044. Businc$ ,nd l'nttasi,ns CGl. I hc ConktIu s Lr.n{ tiw d{s nol |pflly rr an owmr of
<br />rhc p$pcny who $uius or m{rorcs rhcBD. arl sfu dms such w rt hinNcll or hc(clf or rhmu3h hn or ncr .str .nifl.vccs.
<br />nn,vnbd lhdr suulr nlpmvcmns ft nor nlcftLJ ororilm'l lor srlc Li how.rcr. rhct'ui[ingor i'nlmlemnl n$ll1wnhin nc ttr
<br />ofco.{lcridr rhc Owncr Builld w havc lh. t'urlc it I'nin8 lh.r h. ot dt dil rn lxrill or m8)v. rh pNIElv br rh. I[qss ol
<br />l. as o*n r or rhc l'bp.ny, am c\.luriv.ly contacr,rg *(h lutrs'l .onkrcb6 o con(ru.r llE Pojd (s.. 7014. Busincs
<br />rnJ Pdcsssncoic'l[cContacktr'sLrcnscLrwn..sfrnrtplyronownerofnnpc y who hurlds or imlovc! rh.rco.,
<br />dtril wh..ont.chtursochpNjctlssilhaCi,nir&u(rlEnscdJ{nusnrbrh.conthcMsLrcoseLw).
<br />' B & P( hr rhts rcri'l
<br />r\-(-L
<br />I ccnrlyrnar in rhc Fdormn.collhc work n, wh'chrhis Pcirn is i\sucJ- I shru ton cn[['vanvPcB.n t rnvmanrc!
<br />v, m k, L$m subjctr lo rhc ,orksr' contEnsarDn h*solcllirbmii, mJ,8E lDr ill stx'rlil h.com suhj.lr l{' rrr
<br />wo*cr{ crnfcnsrrr.r pnviu,nr ot S.cr un .17(]0 .l ih. I ihr CGlc. I fi.|I. ,on hwirh ll,hnly w h tt()e povisions
<br />IIARNINC: F. ur. r' rdurc workcr' comt nuri.n ..vca!c n !trhwh'l, m'l shdu srbjel cnploltr b dmBal pcnahis a
<br />qvil lnrs trt b on. hunlrcJ rlrnMnJ
<br />S.cri,,n 1076 ol rhc lf,t^tr Cdlc. inlcrcsr
<br />thc ..n .l .om!.nsrin,n. Jantqcs rs FrvLlcJ nr rhc
<br />PECIdMITAN
<br />I lrcrciyal1irm u,xlcr p.nllryo, F.rjury lhd I.o li.tnd unJ.r PDvision otChaptcr 9 (.onmtuins *irh Ser$n 7fi)) o'Divi\ion l
<br />oi lhe Bushc$ ,nd PNrcsions Co,je, rl ny iiccnk Lr in tuU rora a,n c$.cr')
<br />L \1L< b L
<br />colsr8lglqNLElDlNclaIlgr
<br />I hcrc$y lflnn nndcr pcnally olncduryrh,r lhcrc h ! onsrrucli,n bnJn8 rseky nrlhc pctl.nnRc ol rhc wolk ld whi.htht pcmir h
<br />iskJ (s& .109?, civ c.).
<br />Lrnl.,'' N,m
<br />-
<br />I (d,l) 'h.r rhc lcJs.l rpuh,'un\ rlnl'nr r\t{{iF rcmnrr'u. nrr rmlrJhr k' rhtr nn!r. r
<br />.r'
<br />^r'l
<br />Lcn,lv rhar t h,rcrc! rhs rl,nh.rr!,nr', nrlclhrrrh.alt,vc nrt,trm.lion isconccl.I rgre b(ohtlywnh Cnvr.dO,nnry
<br />T(hnJNcunlSrrctlwin'Lrosn,hu'ltl'nrri'ndtudnin,andhctcbyauho.rcprcscnl.tivcsollhtCiryrndCountvk'cnic,ulx)nrrt
<br />$vc cnroncd pn,Plny n'r
<br />Applienl {r AE{nl SisNt!
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf looriVenVlnsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulationi Energy
<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 />Enqineer Final Report
<br />Flood Zone Certil.
<br />I
<br />Certificate cc anc
<br />Notes, Remarks, Etc.
<br />BUILDING- INSPECTOR RECORD
<br />Forms/Steel/Holdowns
<br />FINAL // /b D,c-A-,
<br />uoStrEBS:COUE!!SAT(}!
<br />DECLARATION
<br />I hcaby a,rrd undfi p.mlly ol pqjury oe of rh. inlowine dalealpnr:
<br />-l
<br />havc lrl will minram aCcniiicarc orconscnr lo SclHnsurc nx wolkc6 coqt.salion 0s Foti lcd ror bv Scution.l?00 or rhc
<br />L{htr Codc. nn tlt ,crtoM.c ol lhc &It aor whicn the p.mil is issucn
<br />Xr rrr c anl *r n monrau *orlcB' umncnsir nn miurarce. rs rcquircJ hy Secl ion -r7{)0 of rhc bbor Codc f.r rb. FrforuM oI
<br />' thc\snt lor tr h(h rhts IFd r ,iq.J. My $orkcr' , omlrNrrn 'nturrk c ! ffir anl Flx') numhcr m.
<br />AI'PLICANI Dl:(:I,ARAAION
<br />l)r,$y linunler p.trrlry olP.ijury onc ol ihc lnUowins d.elr'rr()ns:
<br />Dcnn,lirk, PcrnillAsh.no\ Noht,crlotr l;cdcrtlRc!trlxti{,ns (l lc 40. P 6)
<br />RcquircJ L(.'o, Nor'llc otr
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