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SITE-WORK DATE ID/SIG.COMMENTS OlINOR BUILDIiR DIiLCARATION
<br />I hcrcb, lmrn undc0cn6hy of perjury thar I an cxc.rlr riom rhc Conrracro^ Li...sc tjw Inr rhc iollo*i!3 rc!$n (S.c 70ll5
<br />Bu\incss r*l Piofcs\n,n Codc)r Any Ciry or Counry which rcqum\ . Frn ro con(rud. allcr. in{mv.. dcnmlnh or rcprn any
<br />$rucruc, prior b ns isuatrcc, also rcquncsrnc opplicanr fot such t'c,trril lo filc s sis cd srI.'mnr rhar h.or shc n liccn*d puruanl
<br />b rhc povisioN ol rrB Conractor's Licciscd t-rR (Ch,rrf 9, Comnr.cins wilh Scrlion 7(x)0 ol nilhn,n I oflhc ausnrcs and
<br />PmlcssionsCodc)orth,lhcorshcncxcnrflthcrcriomrndthchsi{forlhcrllcsed.i.mPri.n.Anrvioltlio.oiScctbn?O3l5by3i,
<br />lpplicanl for a pcnnir suhjslsrhe appliclnr ro!civilrcilhyotnor.x,crhnn nvc hundrcd dollors (5500).
<br />l. N owncrofthc pru|]cdy. or nycoploles *irh w!8cs !\ th.n srh c.mpcn\arh! *illd. rtr work dt lic rlnrlurc is mr
<br />irlcdcd or oricred for $k (Ss.7014, Blsims lnd Prole$bns C{{1. 1 h. C.nta.iols Liccnr L1w docs not q,ply ro ai owtr .f
<br />rhctmltny wh. hu ildi or inllfolcs rh.ren. rnl wh. d ssu.hwlthnn\clfothcRllorltruuShhisorhtro*n..floyccs.
<br />providcd rhar such i'ntmvcEnk re tur i' cndcd or oficd for {lc If. hosc& th! t{ikliiB or illq)$venFN t $ld wirhi" ,,nc rr
<br />ol ont),lclion. tlE Ow.cr auildcr Nill hrvc lhc tu.dcn of provins rhi tu or \hc did tr.r bui or n\rmw thc pmtdy lor lhc purrxc oi
<br />-1.
<br />asowncrolrhc F,pcny, amcichriv.ly conrrr(i.s wnh licci*d contrd.^ ro .otrnfld riE pmrd (Sec.70,11, Busimrr
<br />atul A.fcsbn Codcr Th. Co tracrol s Liccn* Law docs nor .rply lo otr owncr of lop.rly *h() brilds or inporcs rlfrNn.
<br />md who contrrls lor such Itr.irls silh a C.nracro(n liccn\cd rrr\urm rorhccont!.ktr r Li.cnsc L,N)
<br />-l
<br />amcxcmpl undcr Secri
<br />WoRKFRS' CoNIPFNSATION
<br />DECLABTIITN
<br />t hcrhy,fiii,nundr Fnilryordjxry.trc orrhc rolhsme dcclit.rnins
<br />I havc uxluill'uinui.a CcnifraruofConscdr ki S.lf ln\uru forsorkcrr onrp..sllion. rs pnvidcd lorbyS..rnu lTmolrhc
<br />hhor Codc. ihr rhc Pcrlorroncc otrh. work ru which rhc pcmir n k\m
<br />l hrv. r d w ill irnrrh workcN .orrNnsarn in\urdNc. $ rcqtrir cd [y Scd i(!r ]7m ol rh. l rhor Gdt. fo rlr lErlornurcc of
<br />'r
<br />.", t.,.trh'97 ,.isu.,r Mytr.{tri.r^irr.'r'.tr'NU,Jtr!.lrr(i !rF,ri!rl'+f,J.. /fhlertf,C+zrt,//E/a?vlnt fr -3t/-/lb/- 67 /a a-/F
<br />-l
<br />c.nilyrhlr nr r[c rcrhflniNc ol'lhc worl ntr+hichrhh prnnir is isstcd, I shrllnor cnr oyony!.non in atry manner
<br />s, ,\k! bc.o'tu sxbjcd rorhc wo&c^ onrpnriri.n laws of Calinn nin. rnd!8rcc rh il l should btcum subjc.r btlr
<br />work.^.onrl)crsrrnrtrorisionsofSccrionl?l[ofrhcLitarC]odc.lnEll.tunhwirh.onflywirhrho{povtiotrs.
<br />NARNIN(: IrrilD.c r. ecurc wo*.r' .ommnsdnn, cov.rsc
<br />'s
<br />I subrccr 0n cmplolq lo .nntinrl Fh.xics and
<br />.ivil fincs un lo orc hundrcd I
<br />S(rion 1076 ufthc lrnr C!d.
<br />"*-3 at-t
<br />\r/olc.n{Eni nn. dansgc\ ,\ pn,v'd.d litr rh.
<br />I hcrcby rriiflnundcr |[trrlty oI l,crjry rhui t r r trfd.' Df!isi,rr,)i Chxfrd 1) (..nnNf.irB (irI Sccrion 7(nIr -i r)i!].ir 1
<br />LZA44:ry;
<br />I hcEb! altirm undcr Fnllly ol p.!ju!y lhal rh.rc n ! coo(oclb. lcndine g.n.y fo. thc FdorNncc of lhc work to, whkh rhis Frnln is
<br />hru.d (sd.1097. civ. c ).
<br />AI&TCAIIDICLABAIION
<br />I tboby atrmn uM.r F,ax, oi r.rjury onc ofthc lolloqine dalo,llionrl
<br />D.ff,lnion Pdnns A$.{or Norificrrion r-.dcr.l RcNldilrns (Tilca0, P!n6)
<br />-Rcquncd
<br />Lncr of NotiaEalion
<br />l..nilyrhar I lrlcr.irh'\rprhcrrnnrntul(nrcrlrar rh.rlr)L,Ene r. trtr,tJ * h Jll' i') itrd ( ntrd)
<br />,rlinrncc\ rnd srric lr'*\rcl i"! h buikl rS y.nthorir rcrrc\enlalivcs ofrhis Ciry Md Coutrty Io cfcr ulo.lh.
<br />obovc rEnriorcd nion ny for ins
<br />ADlliclnt or Agltrt liigM
<br />d z/
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathi ng ,/////x t ,/14d24-/h--
<br />Shear Wall
<br />Framing
<br />lnsu lation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Depuly Final Report
<br />Engineer Final Report
<br />/6//f/il t TTzlrrA-,'12-----
<br />Certilicate of Occupancy
<br />Noles, Remarks, Etc
<br />BUILDING. INSPECTOR RECORD
<br />Flood Zone Certif .
<br />FINAL
<br />.f rhc Busin*s end Pmfc$ions Cnd.. rd my liccns. is in tull Ibrc ond cafsr.
<br />I .n,lcr'. NJm.
<br />I .r t,1\ AJJ,.a
<br />_lcrnilyrhr rh.l.,lcrrLrcgullri(,n\ rolrdi'ig \hciosfu r,vrl ,. ror rtitli.rblc lo lhn pm]ccr
<br />:^,,,1P?'6
<br />I
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