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DATE IDiSIG.COMMENTS OWNER BTJILDEN DELCARATION <br />I hercby atfirm hdcr p.fulry or p.rlury thnl I m excmnl fmm rh. Crd r.ciom Li.cnsc lis nr $c rolbwnr8 rcoon ( Scc ?O.l r 5 <br />Busi.css a*] ProLssion Codc) Any Ciry.r C.hry whi.h i.quircs tr lclmir h consdcr, drd. in[mvc, dcmlirh oi rcprt dhy <br />srrucru.c. prior ro irs issuana, aho rcqutcsrhc amlic0nr for such lcnnilro fi|. d sigrod rt0lcnEnr lhal hcorshc i\ licctrsd pu uonl <br />k, rhc Srvi\nnN ofrtE Contmdoas Lien€d hw (cha/.r 9 comnrncina *irh sc.lion 70oo of Divkion 3 oa rh' Ru(nr\( 'nn <br />Pordsh.s Codc) or lhor hc or \hc n crcn9l rh.r.fon od rhc bNir I'or lhc,lLlcd cx.mpiion Atryviolalioo.rS..rion?03l.5nvatrv <br />3mlicanr ior u pcrmir slbjcrh rhc apllic0nltorcivill)cmllyofior rotrhanfivchundrcddollu\($5o0). <br />l. m owftr nl dc potEn). o ny cdploy.cs eirh waAcs as rhct slc comI.nur io.. will do lh. vo* lnd rlt {trlu k mi <br />n cftlcd or ollcrcd tn $lc (S( 7014, Busirrc$ lnd Proicssions C.<lt Thd c.nr&u s Liccn* Liw dtEs trol0tlrlv lo !nowncr oi <br />rhr pDpcdy whohdildsor irirrmEs ltrNn. ald sho d(rsskh{or* hnnsclf.r hcr*lforrhmuShhisor hs owncnPl{,y.cs. <br />providcd rhlr such inprnvcmnk m nor inrcftLrt or (lrqcd nn sb li tx*cvs, rtr builtiq .r in rowrnr h $ld eirh'n om ycr <br />ofconutrio[ rhc Owncr Bl ds willh0rc thc budcn of lrovirrS |hlr hc or \lt dil *n huild or inltrmE 0]c Imldy f.r rhc 0uqns ol <br />-1, <br />* ownf or rh. topcny, am cxclurilcly .onrrrcring wilh li.ctr$d contrdor\ t, .o rlrxct rlE lmjcct (Sc 7(}4,l Btr\i"cs <br />nlrd Prorl\s,oo C.dc:'mc Cotrr&kt * Li.cns. Lrwiocs nor arDlyro riowncr orlml]cnywho l,uildsor impovcs tficrcon- <br />!.d lno co.rhctr ti,r su.h prcj.rls wilh a ConrDcb(9ltci*d pnnumr lo lh. Conr,acroi\ Li.cnsc ti{). <br />-l <br />rmexehpt ond., S..rion-, B & P C. n* thk rc$on <br />Daie: OrnE <br />$onKrRs' c(lil Pi NsA- I{lN <br />I'!(LAAAITON <br />I hrrdby rlttrmundcr NnaltyoiFrjury om oarh. roll.win! dNl,rili()ns: <br />-l <br />hlvc and *ill mi.iain r Ccnrfmt of Conscnr lo Sclalnsrd r.r work.s omPenerioi. ax lilvid.d for bv Ssrion ]700 ot rh. <br />tibor Codc. for l ie pcrto,nhnft o r rh. work for wh ich lhc lcir.l is nr u.d <br />Ih.icnDdwillnuinrrir*ork.rs..nD.nsrrionimurarcc,$requncdbJ-S.rri)nlTL\)otrhclf,bo'Codc.lorlhcp'n'rmadrcor <br />r hc sork lbr shich lhi l)crnir it irsk{. My woikcr( conlpLnsrr ior in\ur {c c.ricr and Flicy nutnhji tuc: <br />l\ri. Y\ i.hrr <br />_l ccnilyrhrr in rhc !.rlbrnEncc ol lhc *ori lor shichthi\ pci,nn <br />\o lso bcconE shtcct ro rhc w{rkcr\ L! rcns n rhwsoicrli,bnr <br />loy iny Fr\on ir 3ny mrrmr <br />I shoul.l h.comc slbjd h lhc <br />nvntr,n\ of Sc.riinr lTm ol rlr lrli{ (1xld.Isli ll. n!1 hcomply,irhrh,$t'n)ri\nnrr <br />Borkcn conpcnslrioi .ovcragc is xtrltwlil nn c.Dlolcr ro !n rinrl lxnrltic\ and <br />rhorsr (lol[rr 1$]lx).lxnr). i,, Inll(rtr <br />nrlcrc{ dalronry\ lrc <br />v rflnfl uMcr pcnslryofpdrjury rhrr I rm licctrsl undct [oenion ofChaplct I (cor lih s&1' ?(xl)l oIDilisi( l <br />nd }rolcs\iqtrCo{tu. xn,l n,y I'rcn\c i\ i'r iullii)r.c i,nlcii.r <br />I hcrcbyain undcr Fnrkyorpcrjurylhar rhcrc n n co :, \.ndurt Jlrctr!y t'r" 't-" |f'to "rxi,..t'rtr sfll r.r "h\hrl.\ Frrn r <br />i\qrd lScc 3U)l.Civ C) <br />L ndca( AdJr..' <br />- <br />A.ITII{:TNLII}:IIdtsAIION <br />Ilrrchyafilnnundcrocnahyorpcrjury.Molrhclbllowin8 (hrrri,ns: <br />Dc rlirion Pcnnir*AstE{os Norilicari.n Fcd.nl RcEulntio.sal'irlc 40. Prn6) <br />Roluircd trller of Notilicali('n <br />-l <br />ccniltthar rh. tcd&rlrcguhrions rcBadins fftc <br />I ccdill(h ! I hru rcmlrhi\ <br />rlxiv. trrnri{,nctl IR,ti{dy ntr n\|E.riqr N <br />t\pplirtr.l or Ag.nl SiAtr.lure <br />{-dne+1- <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFEFI Ground <br />SLAB Floor <br />Sublloor/Vent/l nsu lation <br />Roof Sheathing urnn k futtfl,l/K) <br />Shear Wall v <br />Framinq <br />lnsu lation/Enerqy <br />Drywall <br />Ext./lnt. Lath <br />Masonry <br />Pool Fence <br />T-Bar <br />Handicap Req. <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL ttl/4rt I '.ttturm-to..-/c@ <br />Note.s, Re.marks, Etc - ^t- rt-4 <br />aL 2 <br />BUILDING. INSPECTOR RECORD <br />SITE-WORK <br />Brown Coat <br />ordinrn cs and Srdc tr*s <br />I <br />I