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SITE.WORK DATE ID/SIG.COMMENTS OWNER BUII-DER DELCARATION
<br />I h.rcby rfirn undcr p.nalry ol pcrju'] rhd I di cxcn1fl Ihtr1 rhe Conhcloi\' Li.ctrsc bw ror lnc nnb*ir1g ,q (s.c.7011.5
<br />Bxsircss itrd Pmfe$ion CGlc). Any Ciry or Connly qhich rcquir.s a leilnir ro coNrlcl. allcr. i'np(Nt. dcmolish nr r.nair Jnv
<br />{rucrurc. pri{n b ik hsurtrcc,oho rcquncs lhc atpliclnr ro. ruch Pcnnir ro lilc ! siSncd drcntfi rhar hcor shc h li.er{d Pu(udn(
<br />ro rhc nmvisions ol rhe Conractuas Liensd La{ lchQlcr 9. Cotr1.rcrrn8 wirh Scclion TOln ot Division I ol rhc B!\irrcss ,nd
<br />Pmtcsn,ns Codc ) or rh,r h.or shc is cxcmrl rhcrclon {{l rh. hnsh rur thcnllcAcncicnrpii.n ny vnn.rn,nofScclion 70.1I 5 by dry
<br />nppli.aor foru plnnit subjslslic appli.nnr ro tr.ivitpcndhyol ml nnrclhro livc hundrcd d.llnB (3500)
<br />-1.
<br />as osncr orrh. pioFar. or mycmployes *ilh lascs !s rhdt snc.o,rPcrsolion. Nilldo irt wolk md lhc slrucruro i.\ nor
<br />inrcnL{ or ofiarcd for slc ( Sa TIHJ- Busincs Md Ptufe\.k)ns Coi. TtE Conkactr\ Liccns Law doc\ nor +dy ro m owncr oi
<br />rlr pmFny *ho buildr or ir{r('rc! rls6n. snd wli, &ts such xo* hntr(lfor hcr{lforrhrough his or hcr o*n.rrloy.cs-
<br />pfl,vidcd r hnr such inlPrcvcmnk m mr i .xrcd or olteEn lor et ll lr,s.vcr. rrE hilrins or inY'mwmd n st rnhin onc Fe
<br />.rco'nplcrion. rrr Oprcr AuiEcr willUE rhc briki orl,.ving rru h. or shc ilfrnt ikl or impm{ thc tmFly lor rh. t!,lxN or
<br />l.n\oun.rolrhcmoD.ny. ncrclusilclycdnt rirr! wirh li.cnscd co ntr.tF ro .o nst rucr rhc projccr (Sc.. Toll,l Bu\irrcs
<br />anl thrlssin Cod.: Thc C.nkrcrols Licensc l,aw J.cs roi trPflyro trn osncr ofPrcFn, who huilds or irprolcs rh.r.otr.
<br />aml who co mcls lbr such tbj..k *irh r Conr..ton ( ) liccnrn pur! nr io rh. conrac'ois LicenE lxw)
<br />liD.renlJ, un!1.' S(ri(tr
<br />D!(€ owner
<br />woRI( l rls' ( x lNrPFNsA noN
<br />IECI.A.8^IIAX
<br />I hcrchy aflnmund.r Fn yorr.rjrtryonc ol th.lbllorinB dcchrarn,n\
<br />Ihrvctuxlwillnui a aCcnifi. cofConscnrioSclf-ltrsurctorw.rkc.fc.nlcnsdriofl..s fmvilcrl f{tr hl Sc.rion lTOl) ofrhc
<br />t:tx, Cqlc. fd rh. IdfonMmc .f rhc *.rk iirshi.h rh. l.nnn i\ issucd
<br />-lhivcrrdsllnrn
<br />rh s.rlcs'cnmncrsrrion in\urxNc. r\ r.qrncdh!S!tri(!rl7(x).frhcl.Jhor(ndc fot rhc Pcno rnr'or
<br />rhc $ork fu*hthrhi\ p.rmx ls h{rcn tly*orkcrr conrp. lrri(r nr\nrnmccricr rnd Pli.} rui$duc
<br />l-,, r',".,,"'r"p",r,"""ncci,rrh. {r'l hr rhtr\rn. Pl nr r .'Lnl. l'hJrl
<br />/o r h hc(c,'r {l^i.d r',hc tr *c1.'{nntn'orn1, litr. nr..lil, tri' : rg^t rh,
<br />wortcs conrlcn\rrnnrF)visbnsofScclion:lTmofltc lihxCod. l \hnll. lonh*iih
<br />IV]\RNN(;: Failurc b sccur *otkcs .onDcns ,on .ovcraE. is unlaRfut. and dul
<br />. nil ttre. dt I' nnc hurdr.d rh'iu\J'C lii1tr, r(l'xi'r{'t 1 "idrr{r r., rl'r ,t { ,
<br />Srnn'n lU76 lrh. Lf,br Cod(. tr c,.i,nLlnhN\i1.,
<br />,,.,", -4 /zL/ tl noo;Z Du.., o,*-, a .-/ t x.r.NsFr, (.0N rRAcroR
<br />m! cmnbyany pc^on inrny m.nncr
<br />ii I should bccom snhjccr rolh€
<br />conply wirh rh* lrovhi.ns
<br />I subjccr m cmployri ro aiminrl p.ft'hics and
<br />,r.dnfctrsrriotr. domlc\ ,s providcd ior lhc
<br />1,4r1-,s
<br />I hc'rhyrrlirmundcr pcnllryolr(riury rhar I x li.cicrundcr lmvisiofl of Chsl,r.r 9 (..mmndin8 wilhS€'i,n 7(xlo).rDivkion 1
<br />.l rhc Busincsnnd Ptufcsions Codc. lnd myliccnsE i\ in lull rod drl clliti.'9
<br />"-"7/ZLA4 Dtn e't aliq
<br />lolsrSllcuoNrErDllc-[GENlr
<br />I lrNby trfllnn undcr pcnalry oircrjuryrlur rhcrc n a con(ruciion bndinc r!.ky lor ihc |ariormoncc ol rhc $olk for *hich rhk Fnnn is
<br />i*x.d (S...:1097. Civ. C.)
<br />A.TTLI1;AN[I,i1;LABAIIAT
<br />I tlR$y rrilnn undcr pcnrn, orFrjur! ok ol'thc folbwifs n-r*ii'n.
<br />Dci.lIn,nPcrnrirlAstrstosNorific,rnr Fcdcml RcBul.tions IIillc,l). I'}r 6)
<br />Rcq!ird Irncr,,iNotili!: i,,n
<br />l.criilyrl,xr rtu lrJofulr.!ulnr.n! rcgrnlirE r\h.(o\ r.n(,rnl rrr trurrtdl. 6t r,, rIn Dn)],:.r
<br />-l.cdilyrhd
<br />I havc rcxdrhisrppliciliona'rd nrrcrhmrhcrh)!t inliarErion ncoftcr' I r8re romnrd,sirhnllCirvr Counry
<br />diM r.\xid Srrlc tnws rclirin3 x)nr nM hcrcbylulknnc rcEc{nr.rivcs ofrhh Ciry and counly lo cntcr uF,n rhe
<br />ilDvc rEnrioncd fn|{'itl,tr i')
<br />,\nt ica l.rAA.rlSign.l ,,,,,, */zc/tL
<br />Set Backs
<br />Forms/Steeli Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVl nsulation
<br />Rool Sheathinq
<br />Shear Wall .A
<br />Framinq 7-7o -tY x#('7a)
<br />lnsu lation/Enerqy
<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 Certif
<br />A
<br />FINAL v-224y trN+\td
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc
<br />BUILDING. INSPECTOR RECORD
<br />PolicyNuuhc,, /
<br />Lrndc, .
<br />^dd'....-
<br />t{#Lr(<
<br />I
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