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SITE.WORK DATE ID/SIG.COMMENTS OWNDR BUII-DT:R I'Et,CARATION
<br />I hcr.by {rfirn und.r p.nrlr, otn rjrry rhdr I ah ckc'npr ,nnr rhc Gn ra.t,F Li..n{ ljw rbr rhc r.ll.wi } rc.\ (scc.?0:11.5
<br />ausincs flrd Pronssion Codc): Any Cirt .r O'unry whkh rcqun s r Jf,nnir ro .onsrd.l. arr$. improrc. dcmlish or EI\rn ,rny
<br />srructurc. prhrro irs hsuancc. rls,cquncs rhc trttlicanl tnr such!.rnrirro nbasi-lncd shrcm.i rhar heorshc is lic.n\.rl ,trFuanr
<br />to th. trolisions of lhc Conkrcror's Lic.n\cd tis (Chrlrcr 9. C.mm.n.ing wnh Sc.tion IUD oi Divtion I oi thc Blsirrcs rnd
<br />Perlc$nnsGxlc)orlhnlhcorshcis.rc.rpllhcrclron.ndrhcbusishrlhcnlh8cdcxenDrion.Atrylidaln,norSccri{,n70.ll5btrn,
<br />rypli.rnr ror!Nnln suhj..t rhc Dtplica.r k, a.ivilpcnllryolior mrr rhri llv. hrndr.ddolhrs(S500).
<br />-l-
<br />!s osmr oi lhc pmtEny. or nry cmploler *ith a.Bcs .s rhcn snc con{cns ion- *illdo lhc wort and rh€ nturm i\ rti
<br />i' cnded ororlcrd lor ele (S$ 704r. Bu{iocs and Prolesions CoJc Th. Conrr.ioas l-iccnk trw do.s nor rppl}tuanowmrol
<br />rhclDpcny who huild\ o. inum\$ rhrBnr. {ftIq'h. 'lrcs luch q)d(hnnsclrorhcrrlfor rhoulh hi\ or hs.wncn{t)yccs,
<br />prcvidcdrh su.h n\rorcmnrs m mr inrcnd&lni.rcdl fo.vL ll.lx,wc!c(rhc hu&lfiE or imtrovemnr is sld $ihinom )ta
<br />or L\Eplcrion- rh. owncr Buius sill h^c rhc hurdcn ol Foviry rhor hc or shc did ior laild or nwn,h
<br />'h.
<br />pn,Fdy tu rrE purrn$ or
<br />l. sosncrofrh. rnpdnr- aE cxclu\ilcly conirrcring wirh li..n*d conkrcb^h con{rucr thc ltrordr (Scc 7t!-1. Atrnncrs
<br />inl t\nas\hn Codc ThcContacroi\ Liccn\c La* docs norirplyto atros.crorntrincny*ho huildsor imntuvc\ rhcrcon,
<br />and who .onr n for u.h r$j.tr( airh r Qrtrrr.ror( r liccn*d tur\xrd rorhcconrr.rof\ l-iccnsc hw).
<br />-l
<br />amcrcmpr uMcr SNrio
<br />]!!)BXEBS]!AU[TNS TIANulll narcN
<br />I hcrchy trllirnutrdcr ND{lryol tultrrr_otrcoi rhc lnlkrwir! dt.ldrln,N:
<br />_l hovc ond Nill roinrain iCcnific.,colConscnr r. scll-l,rurc ror w.n
<br />hhora.d..t.rrhcN omDh.^f rhcwol f,trtrhihrhcF"hi F'$uc,l
<br />fILh-o *,,.,,'", -",ror !cm,{n\a,'.n ,,su,JRc r. rcqu1cd/r rhc wb'{ lq *hEh rhii N,,nr I rqcd Vy tr ftkq. omltn,.untr 'n!trd,','iM
<br />tcB compcnsrrion. 0r pmridcd ror brSs.'rion l7(Xl of rhc
<br />tySccrion.lTm ofrne bbor Code. fn rhc Frfonnin.c.f
<br />Lrcc $ricr aml Flic, nrnih.r m:
<br />ttl )41l
<br />_I c.niayrh in rhc p.rftrmam. ofrhc worl fff *hich rhis pcrmir is hsdcd,I shallior empb! rny pcron in ony,noNr
<br />so as k, bNom subjc.l ro lhc wortds omprtrs.rion la*s ofCrlif.mir. ud agEc Ihar ill sh,uld h.sonE suhr.rr b rh.
<br />uorkcN' coorlx,rs.tion pmlisions of s.cr ion l7m of rhc bt r codc. , shnll. fonhs irh .onDly *irh rlrc pmrisions
<br />WARNING: FrailuE ro surc Mrkcfi' con9..sriion co\rag. is unlrwful, 0fld shall suhjccr .tr cmplo)e! ro oimiml Fnahics ud
<br />civil fircs up to oN hutrdEd lhousod doll0r lsl0o.mo). in nddil,ur ro thc cosl ofcompcnsolion. dumasG r\ Fiovid.d f(tr rhc
<br />Sdnrn 10?6 olrnc blFr Codc. intcrc\r ond ortorncyi fccs.
<br />D.le: Appliml:
<br />r rr:rlseir c:o,"lrn-l ctrt)R
<br />IEI;IAIAIION
<br />I hcrchy aflnmlndcr pen.lryofFrju,r rh'r I ad lieo$n lnder pmvnbn o,Chztrd 9 (6nrft ing wirh sdrion 70fi)) of Divisiotr 3
<br />oI thc Busincss otrd Profcsions Codc. d my liccnse h in tuI hre {xl cllsr.
<br />tb
<br />a
<br />CONIIBIJCIIQNIINDING-dGENCI
<br />I heEhy llttm undcr Fntrlryol pcrjury rlrt lhcrc is 0.on(rudior hndire uscmy lor rhc pcrforEn.. orrhd sork ror whi.h rhrs Fnnir s
<br />nsucd(se 1097. civ c )
<br />AITLICANDSCI,ASAIQN
<br />I lrretry afim undcr I'€nalryofpcrjuryonc oilhe lollowin8 dcchrarions:
<br />D.nDlition PftnirlAsb.{os Norifi.alion F.d$.| RrBularions (Tirlc 40. Prf,6)
<br />Rcquimd lrt.r of Noincrttun
<br />-l
<br />ccrrilyrhll rhc lcdcrllr.eulnli(u\rcgJdiDalshcrrostcr.ovrln'c 0.rll|)plicrblc ki rhis IRlr.r
<br />h dlldn[cih!rhc ,vc nrf.rtrrdhn i! ..rc.t. I 0Sr* n) .onuly sirh illCiryrfJ(i)unry
<br />by.trrhorizc rcrc*ntarivcs ol Ihn Ciryand Co!trlr ro cnrcr umn rhc
<br />\r(r4x UIV\Z
<br />Set Backs
<br />Fo rm s/Stee l/H o ldown s
<br />Erection Pads
<br />Sublloor/Vent/l nsu lation
<br />foof Sheathing
<br />Shear Wall
<br />Fram in s
<br />ln su lation/E ne rgy
<br />Drywall
<br />lVlqsonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Reporl
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL I 'Lt lt9 /11/L\(\
<br />Certificate of Occupancy
<br />Notes, Remarks , Etc
<br />BUILDING- INSPECTOR RECORD
<br />UFER Ground
<br />SLAB Floor
<br />Ext./lnt. Lath
<br />Brown Coat
<br />I ctr,l.r'' A,lln'*
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