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SITE-WORK DATE ID/SIG.COMMENTS OWNER NUILDtrR DELCARATION
<br />I hcr.by alnnn undtr pcMlly,)f p.rFry rh l am cicnrpr lron rhc Conrnclon l,i..n* Law ror rh. ,oll,si,,& rcu$n (Sccrull.5
<br />ausincss rhl P(n'csn C.d.): Aiy Ciry or clMry shth rcq nc\ r Fnnir k, coi{ru.r, altcr. nnprolc, dcmlish .r (Tun a y
<br />sltu.lurc. nrior l{, irs issurtuc. ako rcquncs rhc.pdicanr ror such pcmir ro ilcastncd nslcrmnr lhal heorsic is lic.lrsrJ purfl3nr
<br />ro rhc [.lirions of rhc Contr.rof\ Lic.i\cd bw (Chrl,& 9. CoNn.mnrg qirh SccliM 7(XX] ol Diri\ion 3 of rhc Btrsiics and
<br />P(,lissbnsCodc)orlhlrtEorshc is eie'ryI lhcrcfron rnd rhc hasis lor rhcallcscdq.mrrk Anyvidrri(,nois..'htr70ll.5hylny
<br />aptli.a'llnnapcrnrirsrhj(trh.rpplicurk,arivilprrulty.fnoi'hordrhdlrrchundrcddollrs(3500)
<br />-1.
<br />!\ owncr oi lhc pmrEny, or my emploles wirh *a8cs as thcn v,l. comp.$llrotr. rill do ltE *ork and thc sld1urc n mr
<br />imcndLrl or ofi.r.d fr sdlc (Ss ?04.1. Blsincs lnd Profc$ions Conc: rhc Conlrncrois Liccn{ Lls docs nor+Ily ro ri o*i&of
<br />rhc pop.ny wh. hild! or impn)v.s tlrtun, Iwh.ddc{{.hnnkhi'n\clrorh.(clforrhmuSlrhisorhcrow..mployc.\.
<br />pn,vid.d rhii N.h inlm\ctrrnh m mt inrcndcd or.ltaEn forsrk.ll lr$cw. rh. buildirA or ir{,m$rmnl i\ sE sirhin onc ,td
<br />ofcomplcrion- rhcO*ncr BuiBcr $illhovc rhc bur.lcn ofrovins rld bc or snc did rer s{ild or impm{ rhc potf,ny ior thc tntnr ol
<br />l. s.wtrcr.flhc 0opcny. rmcxclusivcly conrracrins Birh liccis{ cotrrrnctor ro construd rhc nruj(r (S( 7(}44. Br\in!\\
<br />,trI ltlsinCodc:rhcG)drrxcnr'rLicctr\dL:wd€\noi!n!lyn'!nowncrofpn,pcnyvhobuild\orimpr.vcslhcrcon.
<br />.nd who c.ntrrcIs for n,ch proFrls qilh Contoctr(s) li.cnst pusuan[o th: C.nfurors l,iccnr llw)
<br />I amcxcnrpr under Sc.r lr & llC larrhh.cavrn
<br />Dnler O*ner:
<br />rvonKE.Ri' comii\saTrr r.{
<br />DEClAlAlloti
<br />I lrrchy nrfiirn uiJ.r pdndryofpcdury om ofrlr folluwint dccldrrio.s:
<br />-l
<br />hrvc d *ill minriitr a Cenificarc of Con\cnr ro Sclf lnsurc fu $orkcn dnnpc.llrtun.,\ nn,vid.d ror bysccrion]Tfi)oirhc
<br />t;rbor codc, ior lhc pc.iornurccolth. uo* lorwhich
<br />'h.
<br />pc.nrir ir issucd.
<br />_lhlclndsillm inluin workcs .onrncDslri,n, insurrncc. rs rcquncJhtScrri,ni:l?(XJorrhdljhorGJdc.L.rhcI,crlonunccot
<br />rhc*ork&.*hichlhn0crnriiisisuslMy{orkcnconrli.nsdionin\urrnc.crricrddF)licyt'nbcrrcl
<br />-lccrliiyrharinlhcp.rf.rmneoirhc$orkforNhichrhh!.rnrhnsocd,I\hrlitrotcmpk',r.yp.rcnindtryh'Jnnf$ Nk,b{rcft srbF.r tr' rhc worl$J .o nrrcnsar i(,n lnssolcnhfomir trd +furhd ifl should i..oE uhjecl rorhc
<br />s.rk.^ .onur \rrionInr^n)i\olSc..oi:l7llrof rtu l:fi,(inlc. I plywirhlhosfrovi\ion\
<br />WrUlNlNcr t',ilurc b *cur. {orkds .onDctrsrlion .ovcrrlc iccr an cn'pk,)ri ro diminrl pcmkrs md
<br />.ivil inrs up k otrc hu.drcd ihous!trd dollus (SllD.txD)
<br />Scctifl 1076 of rh. tjtrtr Codc. intcrcst iltd allormyt lccs
<br />n!^-n!arinn. d mgcr rs lrovidcd tor rhc
<br />DEEI,AB{IIA!
<br />I h.rby rfitn u d& Irnahl of l[rjury r)tir I dl l'c.r\c,i r dd ,rolnnnr .f Cha0d 9 vilh Sccrion TlXx)r orDivi\n,n.r
<br />ot ihc Bu\in.s ann PolcsionsCortc. rftl
<br />'nv
<br />liccns. i\ in lu ll lntuT rrl ctr..rIt7 (
<br />4i 1-t1-tb *.*"."4
<br />I hcEhy rlfiflnundcr ncnnllyofpcrjurynu lhcrc i! B onslru.lion hndins uacmy ntr rh. Frroiirun c orrhc woA t6r which rhh Icnrir is
<br />i$ucd (SLr r(|)7. Civ C )
<br />Afg..lc6NLD[CLA86.rI0!
<br />I h.r$y.ilinn undcr Ftrrlty olO-rjury onc ol lhc rolhqnrg dc.ltr.riotrs:
<br />DcnrlibunP.rmic Asbcio\ Norincario.Ild.ral RcSrLrnnr\(Tiilc.l0, PM6)
<br />Rqun.d I crr.r olNordl.rrioi
<br />-l
<br />lTnilyrhlr rl[ Itdcral rcgul{i,nN rcganlin8 lstic
<br />l.rdiryrhd I hxrc r.rdrhi\r|thcaii(rr xNl \tr Nconer I a8,a ro.onrtly with rll ciryrnd counry
<br />r'(Lirxtr.(\ trlsrr.IrR\ruxrrct,htrirli'rt.[ornc rclr.sc turivc{.lrh\ ( iry ift] (onnryb rtrr.r utx$ rhL
<br />rh\c 'Entioo.d pDtcny l,or i'rp.crion
<br />Appliunl or AICnI Si*nolure 7- /t-tra
<br />Forms/Steel/Holdowns /o.2.,-l6.tq /rd/*-*c ,*D
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />FINAL /f/7 "/ /,4lry (z1)
<br />Certilicate of Occupancy :
<br />Notes, Remarks, Etc
<br />BUILDING- INSPECTOR RECORD
<br />Set Backs I
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