|
BUILDING- INSPECTOR RECORD 4SITE-WORK DATE ID/SIG.COMMENTS OWNER EIIII,DER DELCARATIoN
<br />I turc$r aflirm uMcr p..ally of pcrjury lh0t I an cxcnrrr rtum rhc o)nra.klr Li(ns L2q ntr lhc followinr rc*'n lscc70:ll5
<br />Butin.ss and Prolcs\ion Codc): Any Cir, or County which requtcs u pcrmir t) (n{ncr, alrcr. nnflovc. rlcmlish nr mlitr n]ry
<br />slructurc- 0rior to ils issu.rcc.oho rcquncs rhc arpli.ntrr rrtr iu.h p.rnir ro lilc r signcd stltcnr lhrl hcor shc h liccnscd puruqnl
<br />t(, rh. ptuvisn,ns ofrhc Comra.tn\ t,iccnscd tjw (Ch!flcr 9, CoflrmncinE wirh Se.rion 7fln of Oivhion I ol rhc Busin.$ nnd
<br />Pdts\ionsCodcrorrhrrh..ishc N.rcnDr rh.rfnrmd.d rh. h!\i\ for rh. dL8.d crcmption. n, vidrlionofSccli,n 7011.5 by.ny
<br />!!pli.,nl lor aI'eirnn suhje'srhc oppli.i.l ro acililpcmkt.fnor mrc rhnn fivc hundrcddollus (S50Or
<br />-1.
<br />* oBNr ol rl[ nn,Fcny, or ry cnrdo)es wnh wnsos ds lh.n v)h ..nrFnsdi.tr. will do rhc *ork and lhc sltrrure i\ rr
<br />inrcRLn oroaicrc.l lhr salc (Scc 7(!4.llusires and Pmfc$ions Codc Thc Conrrlcrofs Liccnsc l,s* doc\ nor apply b rtr.Rkrol
<br />rh.fmFlry wh. builds or in{,tuv.i rh.mrn, nnd who der lkh m)rk hnns.lfor hcFcllor rhrouSh hn or h.r o!'. cn0loycc\.
<br />prcviJcdrhar such in{mrcmnh m mi inrcndcd oro'IcBl lnreh ll. ho$crcr. ihc t{ildin8 or impdvcnEnr h soki wthrr otrc ,!ar
<br />ofc-n{hlion. thcOwncr Buitcr *ill hsrc ltE hfthn ofpmvirB rh,r hc or shc dil mI t{ikl or im,row rhc pDrEry aor rh. purlnr.r
<br />-1.
<br />a\owncroflhcJ,mncny. amcxclNivclycofiaclir! wirh li.ctrscdcontr..rorloco.(r!clrhc nmJccl(S( 71X4, Btr\i"r'\
<br />d lh ir\im Codc 'l'h.Conhrcktr s l-i..isc Lr*do.s nor lPplrt, rnolvicr ofF)pc ywho huikh or irororc\ l[.rcon.
<br />rnJ who coorracrsfor such prorccr!snhtrCotrrft.rons) lienscd Nrunnr lo rhc Conkacttr\ I-icrn{ ltrw).
<br />I rDr.xc,nnr und{ s&r
<br />uaa[,tr&ll1;ourENsa:uoN
<br />l)&clAEaIlQ!
<br />I hrrcbtafln un{lcr pcnrlryortcjuryoi. ofrhc rolk,sn,E d\-.lumrt,nr:
<br />lhr\.a*lwlll ,rinrri'r3acdifi.rrrolCon\rntbSclrlrNtr'cfttrtrorkc^(nt).i\ i.i.r\t()wtcdhrhySLrrionlT(x)olrhc
<br />L'htr C{\lc.lhr lhc pcrlonnrmc olrhc *r lnr{hichrhc,uni n istrcd
<br />Ihtrlcrid*illn,ri'di'iworkcri.orrr\di{nnNurrncc.r\r.qunrdhySccri(r]Tm.frhtl;,horCodc,Lrrhcncrlhnninccol
<br />rhc sork for qhich rhi\ |f, rnir is i$tud Mrso urr conrpctr\rrn,n inruruncc.nicr rr Oni.y iu rhci sc:
<br />cr.., - 57*7-.'
<br />9 6 7 o e19 I . // -/-t8
<br />I.cnily lhrr in lhc pcrfornrncc,n rhc *ql lbr whi.h rhi\ ncnnir i\ tsucd.I nHlln.r cnlrl,i), ,y pcrrtr, i'1nny trrtrncr
<br />{, r\h lf,d f, \uhicd k, 1hc s orkc^ .o rfci{rbn has rt Crlin)n,ir. r d qcc rh.r rt l dx,u U lE.nr. n,hjc.t nr rhc
<br />\ork.n.uIrn!irrrnn,viriiJn\.fSccri( l70O.lrhcl-nlinClxtc.l{lull.tu hrirh..nlnywirhrho{nntri\nnN
<br />WARNIN(; lidihrc t, *-curc $o*.r\ c. rFn\ari()n co\.ru8r i\ r h$lul r d \hrll {rht.r dr cnrdo)rr r. Lrrnnnrl |{nxlri\ rftt
<br />ro o c hu dr.d rlnru\rnd dollrr\ (sloo,(xx)r. i'j ddirnnr ki r,f, .o{ rf.or np.n{arnnr. dimscs ns nnrvtlcd tu rhc
<br />F.-4a:t2
<br />DECIJAAIIO!
<br />I hccby lmrmuodcr pcnllty of pcrju,y rhrr I am licetrxn undcr nmvnion ol Chlrls 9 (commncinp wirh sc.ri.n 7000) trDnisi.n I
<br />of lhc Ausincssond Prcfcssions Codc. lnd myliccnE is ir lull lorcc and cftct.
<br />C.9z'1 > 2_6 r
<br />u"" *-Za- f 2
<br />IONiIBU(:[()NIENDIXI].AGI'N1;I
<br />I hcrch,Jtfi"nu cr Fnnlry ol pqjury rhd rndc h(<'nslru.rion lcndinsrscncy nn rhcpc ornuicc.rrhcw.rklorwhichrhi\Frnrith
<br />nsucd (Scc.3097. Civ C ).
<br />ASTLICANLIECIABAIIQN
<br />I hctr$y anirm undcr ncn0lty olpcriury onc ol lhc i,llowini dcclomrions:
<br />Llnnlilion Prnih- stE(os Nolificarion l:cdcrul Rcgul0ri r (Tirlc,l0. PM6r
<br />-Rcquncd
<br />t.ttcr of NolifEarioi
<br />-l
<br />ccniiyrhd lhc l.dcxi rc8ulalion\ rcgnlin8 ffh.slos rctrDvrl {rc nor !pplic$|. t, rhi. pnlccr
<br />lcdri! rhrr lhr\cn lrhi\rnfli.inn, xn{ln r. rharrh. xhr. iff{trmiln n.orcd I ngr$ r.r .omply wirh allCiryond Counry
<br />rhh Citr rnd Counryro cnltr uJl.nllE
<br />t',b 2-23- 19
<br />o'dnrn.r\rnd Srr.I r\r rcl rt,gt)ikli'rC coi{nctnn,. lnd hcrcnv aurhornc qn$rf hr'}c(.f
<br />rhrv. mrrioncd fl.pcnylhr im
<br />\DpliuDr or,1[cnr si{nrru
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVl nsulation
<br />Flool Sheathino A-n- lR A2',t)
<br />Shear Wall ll
<br />Frami ng
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lalh
<br />lt/ason ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />En gineer Final Report
<br />Flood Zone Certif .
<br />FINAL 6/50 /l'6 ,D(g
<br />Certif icate ol Occqpancy
<br />Noles, Remarks, Etc.
<br />Brown Coat
<br />L{'J '. \d,lr*
<br />--T------
|