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SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDEN T'ELCARATION
<br />I hcrcby nrfinn undcr p.nnlry ol'pcrjury rhar I !m excmpr fmm rhc Conrrador' t,i.cnr ljw ror rh. rolk winS rcrRnr (Sc.7011.5
<br />Eusincs aDd Profcsion Codc): Any Ciry or Counry which lcquircs a pcrmir b con(flcr, "lrd. im,rmv.. d.aDLAh nr rcFn ;ny
<br />drucrurc. p.iff ro n\ issurcc. al*, r.qun.s!h. rrpli.ur n, ru.h tinnirh ilc r signcd sr{remnr rhsl h.or \hc i\ li.cn*d Pur\u r
<br />l. rhc p,orisio.s ol rhc Contructois Liccnscd L!{ (Chlpler 9. Gnn.tn.nrg snh scdio. Tuxr ol DivGion I olrtc Brsin.s\ ahd
<br />tloli$ion\Codc)orrhtrr hcor\hc hcrdnDr rh.rcn.n Md th. ha\is f.r thctrlkscncxcmDliotr AnyviifirionoiSc.ri,nT0.ll.5Dyri,
<br />a|llic,trr ror . pcflnir sublccrs lhc amlic!.i lo n civil lcm I' y ol nor mrc rnon 6!c hun&cd dolld (l5m).
<br />_1. as owncr of thc rmFnr. {, ny .mpk,r$\ *irh s!!c\ a\ rhcn sb .onDctrsd ion, will do lhe wuk u rhcsrddr! n nul
<br />inrcrH or oflcrcd f{n ek (Sd 7044. Busincs md Prufcsions Codc Th. Conlru.rol s Liccnrc ljw do.s nor tFply lo .n owmr oi
<br />rhcpnrD.ny who builds or in{'(,!c\ rlEron. od who d{rs {ch vd( iinxe,lor h.r*lf.r rhr.u8h his or hcro*n cflrployccs-
<br />p()vidcdrhd such nntbwnEnr ac nor irrcftlcJ .r . flcrcd tur ulc.ll howc!c!. rlr huilding or i'ryrorcm.r is $il qirhi ,,nc )tr
<br />of.-nphrion. rlr O$ncr Build.i will har rhc bud.tr ofpnrving ttux hc or sh( di1trol ttriE or nnnnlr thc nmFry fot llE lurrrc ol
<br />,. a! own.r of rh. ln)pdy, u ct lrsivcly.otrha.rir8wirhli.cnscdconulcrorki.on{ cr ih. pml..r lscc 7(l}4. au$nc$
<br />dnd PioL\sbn codc Thcatnlmctofs l-iccn\c trwdo.s nor opplyl. rnowncrorpn,Pcrlysho btrildsor nnPrnvcs rhcrcon.
<br />n who conrDdr f{n sorh tn.irh wirh a C.ita.ro(s) li.cns.d l)unuinr to rhc Co rucror'\ t,iccnsc ti*)
<br />I rm.\.n,ln u Li.' Sc.r o B & P(' lorrhi\ rcr\on
<br />l){ic Osn$:
<br />rY(tRI(ERS', colrtrENsr\itoN
<br />DT:gL!.EAI]I}I
<br />I horoby lltrmundcrpr lr)ol t)crjurtomrlrhcnnhrilude.l.irrit{!
<br />l hrvc r $illnhinr,i'rrCcnni.rcofCoNcnrroScll.ltrstrrcntr$ortcrs.onrcf\ari,)n.r\!n,!cdfrnbyS.criurlT00ol'lhc
<br />lnhff C{\lc.lnrrhc pcli,nnincc ofrl[ work for qhi.h rhc lfhnf i\ rsucd
<br />I havc ind will huinlair *orlcrl confcn\alion in\uramc- a\ rcqutcdbyS..rin:l?0OofrhcLrborConc.t)rrhcpcri(rmai.c.f
<br />rhc sork tu whi.h rhisFnnir is ns.n. Myworlers conrpcnsalidr insurocc.trri.r dd lxri.y trun$tr.rc:
<br />-l
<br />c.nilyrhar inrhc p.rronnrn.coirhc work ior qhichlhn |rirnil n is\ucd- I \hru n.r cn{'loy,Dypdson ir {nynntrrcr
<br />s mrotrronrsuhrrllorhcwo cr'conrEn\iion h$otcllitunia, nnd r8{c rhd ifI slrrld bccam subjccr rorht
<br />workcN drFctrslrion pmvnions ofSsrion:t?m o,rhc ltrhor Codc.I shrll. f(dlrwirh.omply wirh ttuc pmrisions
<br />NARNIN(: |rilurc !, {0.r'sork.ri cr rrt srridr (,trrfus. r! utrliuli']. rd nHll .r atr cn,Ih,ycr r, dimin l t[Mllic\ rtrd
<br />n n\art . dinr[cs as novi cd rbr rhccn'l I'nc\ uI 1 ,
<br />'c
<br />hunJ'.J 'housrnJ doll0^ 'SlUr.rrr".il: ip d1l;;
<br />IhcEbyafltrundrr pcnaliy or Frjury rh, I a li.c.sd undcr pmvisior oiCh! cr 9l.ommrcing *irh serbtr 70oo) ol'Division :l
<br />oi rhc Busircs.nd ProfcsionsCodc. ud '!y liccnsc is in loll roR. ,Jrt cftu.t.
<br />c53 3)t
<br />X'
<br />coNsraucuo rENDtNli_dlilNcl
<br />I h.nhy rfinnundo Fnrlryol p.rjury rhar thcrc n a con(ru.ri,'n lcndi,g dgcnc! for rhc Jf,rionMrcc oirhe s'o!k fff shich ihi\ pcrhn is
<br />issuctl(S .1097.(-iv C ).
<br />l.cnilirl llxtrcrcrdrhisrppliQri(nrdri{rr.rhJrrhcrhnr i,rmirion hc.r&r I rtrr r...'ryly wnh all Cilylnd Counly
<br />onlim.ccs und shrc ti*r rchrioe b hui lt Nlho.izc rcprcscnlarn?s ofrhis Ciryaod Coxtrr, to cnlcr uNtr thc
<br />h,vc rftrridrd |!oNrrytu iNpcdiu
<br />Applicnnl or AEenl SiEn.tuE
<br />Prmilre nonrlprinl):(/-EtLLrr='/t/a
<br />Set Backs
<br />Forms/Steel/Holdowns p-o1 6"-,O14nA
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathino
<br />Shear Wall
<br />Framinq
<br />lnsulation/Eneroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlasonry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flqod Zone Certil.M;b tu rD .f,4 At_16 Wizdls :D<b
<br />FINAL thtLtd 5. ?S
<br />Certificate ot Occupancy
<br />Notes, Remarks, Etc.
<br />BUILDING. INSPECTOR RECORD
<br />T-Bar
<br />s
<br />AIILICANIDECI.AMIION
<br />I hd$y ofiim und$ pcnahyofpc,juryone olrhc lollosins declarurn,ns:
<br />D.mlirio. Permih Asb.sos Noriti..rion Fcdcral Resulations (litlc,l0. Pan6)
<br />_R.quircd1.tr.rorNdric ion
<br />-l
<br />ccnifylh.r rhc tcderalrcsohrn,ns ngdding.ib.ior i.mvllarc nor lPtltot L h rht pnjd
<br />: LLz4tfi
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