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BUILDING- INSPECTOR RECORD <br />SITE-WORK tD/stG.COMMENTS <br />Set Backs <br />Forms/Steel/Holdowns <br />UFER Ground <br />SLAB Floor <br />Subf loor/Vent/lnsulation <br />Rool Sheathing <br />Shear Wall <br />Framinq <br />lnsu lation/Eneroy <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 />Engineer Final Report <br />I <br />FINAL )/2.//l ,n ffi471 <br />Certif icate of Occupancy / <br />Notes, Flemarks, Etc <br />OWNI]R BUILDI]R DELCARATION <br />I hd.hy afl,rn und.r p.n.lly of !.rjury lhsl I Mr cxcnpr fmnr ltc Conrruch^ t-i.cn\c La{ ror rhc lollosirs reason lscc 70ll5 <br />Busnrs( md Pi('fcssio. Codc): Any Ciry nr Counry *hich rcquircs a p.nnir ro con{f, , ahcr. nnProE. dcd,li\h or Epan My <br />slnrcrurc. Drior ro ns issuancc, llso rcquircs rh. ipplictrnr t r \kh Fnnit ro filc0 sisncn sl cmnr lhlr heot ahc is li.cn{d Nrsuur <br />u rh. F)lisiotrr or rlr conrmctors Liccn\cd L0w (Choprcr 9- Commcncirs wirh s.cri.n 7fix) of Divnion :l olrhc Busint\\ ,rd <br />Profc$iur Codc) or rhar ncor!h. iscrcnrpr rbcretomsndlhc h i ftxrhc rlhScd crcorrion Anyliohrn,nofSdrbnT0ll5hyntry <br />apnlicrdn,aFmir\ubic.Brhc{'!liGnrto!civiltcn.llyofnrnEcrhlnlivchxrdrcddollrn(t500) <br />l. rs osncrol lhc rrroFnI. or m!cnDl,,rccs sirhsrrc\ N rhcn wrccomFNnlion. silldo rhc iorl rnd rh. (du. n tur <br />inr. cd or olitBl thr {lc (Sm 70il.t. Bu\im\r rnd Pn,f.sri.0( Cclc: Thc a! racroi s l.kcn\c I r* dl,c\ n.r .rnl, to rtr o\ rcr ol <br />rhd pn)n dy who hrilh or inuo\ c hcBn lnd *h. der such sorl himsclf or hc$c]f or rhhoEh h is or h.! o*r cmployccr, <br />trulidcd rhrr s'ch inlPnivc rih .rc tr ir dk!.r! or oftcBl f(, \,lc ll lrw.r.r. rh. 6uildif3 or irxrtnrnr i( {td wirhi" onc )t <br />of co lpldion. rh. Oq'*r Buildcr $ ill h.rc Ilt hnd$ or Drcling rhd h. or shl did mr tlild .r nryrt,( rhc nn,Fny i, rl[ Purtr'e ol' <br />l.rsoqncr.lrhcpn,nny,nrcx.lu(ilcll.ontNir!rirhlr.tr\crl.orlrrcroFroconntudrhcrn+.r(SG-7rrt1.Btrsi,E\. <br />.M lh,fdsirn Codc Ihc(otrlrrclois l-i.ctrsc LrN(bcs nor $plyro an.wkroflioNir, s[o nuik\ or inun,rc\ rhcrco. <br />and *ho conlrrc(lor su.h projc.r! trirh r comnKti s) ltatr{d PoNrrrr kJ lhc Conlrid,,\ l-iccnY hw) <br />I rDrd\.,npr rn,lcr S.rrir) <br />I)!lr (hftr <br />rvrtlxirrs trntpr:rs,rt (lr <br />llD(l .8Alll}r <br />Ih.rch! xlfnmrf,ld' |xrrlr! ol ti'I ry oN .l rhc n,lI rnp(lc.lr ioN <br />lh,v.irxl willnun nm0Ccnific.rcofconr.rroSclllnurcforworkcrs..nrrcn n,n.is providcd lor br Sc.rn '.l70lr.rrh.titxn C(xlc, r{r rh. p.rrodhn.c ol thc work for which rhc Frmil h issucd <br />Xl hove rnd will miinlain wqtc6 .omri.isirn,n insorat.. as tquncd by Sccrion .l?u) of I hc lj$or Codc. rot thc Pcrr'ornurce ol <br />lhc work tu rhichlhn pcnnir is nsu.d My *orknr' dnn .nsar ion intunncc caricr an l Ix licy nunh.r d.l <br />o D Qor- L l''-zt-t7J/ct nrrr".Z-: <br />I.cniryih r i', rhcFnnrrnr ..olrhc v.rl lor Nhi.hrhis D.nnir is i$tr.,|.1shrll orc .yrny |x6.r irrn, nrMNr <br />\' r! t, tr.orrc nrhFcr ro rhc wor [cr' conrp. nuri,n, la*s of Crlitutr,ir. rnd iglcc rlrd il l (h.uld bc.om sohi.lr h r)t <br />workcr{ onlrn\{nnr fl o\ i\i,ins ol S.cr i(r .r7 rol rhc ljktrGxtc.I sltrll liJnhsih.omply * iih rho{ pnr nn ! <br />IyARNINC Flilno h \c.urc w.rkcis'.onlF.siriotr carcmgc is unhwlnl. xnd shJll rulc.r r c.rDloycr lo cnn,i' l If,t hics Md <br />ci\il fiu ur k) o d hundrcd rhouend dollrr (Sl(xr.(x)O). if rddirnnr k, rhc.o{.1..n{cnsrri0n. dlmrgcs r* lloridcd ht rhc <br />,,"*.- r-)- /k <br />^ppl <br />)C <br />!!l!Lu!ul <br />I hcEby .ritnr uMcr pcnahr oi pcrjuy rhar I !m li(n*i xndd pt,risiotr of Chrfls 9 (com Eciig uirh scrhn T(xro) ol l)ilhion l <br />or thr Businc\s rl]d PruacssiflN Codc. and my liccnsc h in lull fitrrt ,fd;ft.ci <br />a I ?7 07Y <br />-itr .tV- (2,..,c) <br />co!9rBl]cllNr[lDllcaiEN(I <br />issue.l rscc :l0r?. Civ. C ) <br />Irndcrs NnDc <br />-At,t,l,t( AN I DI.t( 1,.\R,\t 11 )N <br />I hcrdy ofiim u.dcr pcnait, ofFrjury om orlhc r.llowin8 delarations: <br />D.nslirion Pcrmiu'Asbcslor Norilicario. F.ddrl R.su lcr io6 (lirlc 40. P0n6) <br />R.quncdkllcrolNolific ion <br />A.crrly lhn rhc ledcrol rcBdhrFn( m8dd'nE trh.{o. mmlrltrrc nor.nrlrahr. rc rh" I,mJ.cr <br />-l.cnifyrhar <br />I h,v. iead lhis trrplicariono'dslalelhol th. atovc nriorturi.n is.omct I 0Bre to coryl, wnh sll cny .nd County <br />onlnrmc\ trd Srrrc l.nN\ (_ld buildinr condruclion- und hcrcbyaLrhorizcrcfrcsctrl.riv$ollhi\Ciryrnd C.tr rylocn,ctut.nrhd <br />oir nEnrioned pDpcdy fff in "z-- <br />6-e5 Tey/o-",,,-r-)- ltr <br />IDATE <br />Erection Pads <br />Flood Zone Certif .