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SITE-WORK DATE ID/SIG COMMENTS OWNER IIUII,DFJR DELCARATION
<br />I h.r.hy rllird xnd( p.n0lry {,r Nrjury (h,r I a r .rcnll)r tror rhr C.nk..ior' Liccnrc Law hr rhc follo$ins rcasn (s< 70:ll 5
<br />Bu\incs rnd Profc$n,n codc): Atry Cny or Counry whi.h r.quncs a pcnnil ro cotr{n,cl. alrcr. inrprorc. dcmoli\h ot rl{ir dny
<br />slruclurc, Fior ro ils nsuarce. llso,cquiEs rhc aptlk.nr tor such rrniir lo filcasisncd {dcmnr rhnr h.or dE h lic.nscd lursurflr
<br />ro lhc pmv(bns ofrh. Conrr.rols Liccnscd bw (ChiBci 9. C. rmcRin8 wirh Sc(ion ?U)0 oi Divishn :l ofrhc Busincs ,trd
<br />Pofcscn,ns Codc) or lh,r trorshc iscxcq)l lhcrcn.mmdihd b,$s ra.lhc allcecd cicnrtrion Any vi,nrrionotSdrionT0ll5hynny
<br />rrplicatrllorapcirniisuhj(*rhc.p!lic{trlto0civil{,cnrlryotrcrnnrcth.nfivchundrcddollitr($50o)
<br />I. .i o{mr oi rhc nmFnt. or nry cmployccs qilh w.8cs r\ I hcn \nc conr|{rsd ion. sill do lhc $ork und i& rft1m is mr
<br />i'rcndcd orottrcd r'or sL lSa.7044- Busincs and Profcssions Cdc: Tic Conrrackni Li.cnsc tf,w dds noi atply n) an owns oI
<br />lhcrnincdy rho hoildr or iqx)rcs rhcN).. Md who dms su.h sorl h'm\.ll.r hcs.lfor rhniu3h his or hcr osn cmpbyc.\,
<br />pn)vidcd rl such tnpr.h rnh tuc tror ir cftLd orolt.Rrl for {lc la h,xw. rh. brilling or i'qmrcnrnr ir s,lil *irhin oft }tr
<br />olcon lcrirn. rhc Osrcr Buitn. *ill h!rc rhe hd.n ot provins lh hc or \hc did nor buiH or irwmve rh. r,Dpcd, rur rhc puii$ or
<br />L arosnerofrhc propcny. !mcxchsnelyconrradins wirh liccn\ed contrctx t, c.i(tucr rh. pmjc.r(S( 7rB,l. Bu\inrs
<br />md PinlssNn Cotlc: Thc Conri.ntr s l-i.cnr Lrw docr n.r ntply k, in.wn.r olnr.Fny sh,) hnild\ or nnpmlc\ rh.rc.i.
<br />rtrd who contr.r\fd \!.hpnuc.hqirh. Co krcktrlt) lircn\cd Nr\u rorhcCoNn ktr s l-iccNe tjq)
<br />I nr.rc tr xi .r s..rnr ,B &PC irrhirc.s.tr
<br />DolE: OBn.r:
<br />woR(E(t, coliPrNs^iraN
<br />IIES.AAAIIO!
<br />I hcrcbylffirnlndcr pc.all, or pcrjrrr.i. orrhd aollo*in8 d(lrarionr:
<br />-l
<br />n0vc ud willmaintrin!CenlficarcolConscnr ro Sclilnsurc lor*orkc6 co'nptm tun.dipii,vid.drorirSclionlrmolrhc
<br />tihor Codc. tu thc pcrform.neollh. woli lorvhichthc ps'nir h hsucd.
<br />Ihr\r nnd qiliDrrlnrrin *ork.ra conlll. \rri,nr in\urrmc
<br />rl s, 'r r:r qhi.5 \'. t(' i\ tru.J \lJ tr.rk.. ! .,{nn._t , l-
<br />..,,,,", -. ltr{fz {.utVl
<br />,trs r.qtriRd by SNrion l7lD.frhc Lrhor Codc.lor lic ncrfonnan.. ot
<br />n\dn,n in\urxmc..ft icr dnd rxricy nunrh.r nrc,
<br />- qux<Itxptcs: ! <l.l
<br />-lccdilyrh.t
<br />irrhcF*rh nrMcolrhcworklorwhichrhnpcrmirisi\su.d.I\hnllnorcnpk)yrnypc onhany rtrtrcr
<br />$ r!t, trconr \trbi.r n, rh. *oik.^ .rmp.n\dt,i htr\ olCrlinn i.. rnd ilnc rhd i, I dmuld t$om s'bJc.r i) lhc
<br />sork(J com|c s ii,. ptuvhrns of S$r n l?(x).f rhc LrhtrCr)dc.I shr!1. tunhsirh .omtly wir h rlm{ pr,lnn,ns
<br />WAllNlNG. F.ilurc ro scurc sorkcn'conrpcns,rtrn corcEgc is tnlawlul. Md \hall sut]]..r r cnrdoltr l{, ri,niralF-trrhics md
<br />civil linc\ up r., om hundNd rhoosrnd dollar (Slfir.lXn). in rldirn,n b thc.on ol.onrlrnernnr. drtrr3c\ r\ provtlci i,tr li,r
<br />s..rir .ri)7a.rrh.lxtrn(i .. nr.r.{ rnllxrh
<br />-R-zc.irr I
<br />I hrruhyxlllrmrndcrpcnrhyol tc'pryrhrr Ir r li.cnscdundcrnn)!'si, o 9((otrnEn.irg$irhScclion7r(X))of I)i!^n :l
<br />.r rhc ntr\i'Br rn,l P(,risirnN Cotlc, md n,y li.rn{ \ i'r lnLllnrrcrtrqrllc(i
<br />B ils!PtlqzQ*. -</a,:lrY
<br />caNllS!,lculMlENplN{illiENlr
<br />I hcNby rffunr undcr FMltyofncrjurylhar lhcrc h!con(tuctio kndir8 rgctrcy lu rhc l.rLnMn.c .f rhc aork lar whrh rhis Infllir is
<br />kcu.d (scc .1097.civ. c )
<br />AIIIJCANfDI,CLA.EAI,ION
<br />I lrtoliy rtnnr u Mfi Nrnlrt ol trrlur! onc ol rlic idlow$A dc.larrrio N
<br />D.nrliri.n Prnnirs A\h(do\ Norilluriir FaJcrrl R+rl rn,i\ (Til.,1l). Pdn6)
<br />Rcqui6d lrkr of t{orificarirr
<br />-l
<br />ccnilyrhor rhelcdcrulrcslh'ioos Eeardiis lsh.ror Ernoval a tur ippli.abl. ro rhis projccr.
<br />LI c.niry rhnr I havc r.ad rhh trprliiartun.nd sr0rc tnrl lhc at$vc inlonmlion h cotrccl I osrE lo onpl, wnh all Cir y 0nd Counry
<br />o,,ln[rcc\ rnlSrrrc I r\\ to]xri'r! ni trizc rcDr.scnrorivcs oflhh Cn, and Counryt,.nr$ ulx,' rhc
<br />rho{ nf,trri{nrcJ frtIrat f in\
<br /> pplic!nr or \t.nl Signnlure
<br />W'L1LtL
<br />*," t/volrt
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFEB Ground
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Enerqy
<br />Qrywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Itrlasonry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />FINAL vry/t{6Atg
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc
<br />BUILDING- INSPECTOR RECORD
<br />I 'J{'.^'l.l'.s
<br />7
<br />Erection Pads
<br />Pool Fence
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