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BUILDING- INSPECTOR BECOHD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARAl'ION
<br />I hcrchy afinn undcr pcnrlly oa pcrjury rhat I m cxcmpl liom rhc G)nrrlcr.is Li..n\c tjw lar rhc lollowin! aa$n (Scc'70315
<br />Bu\incss ud Prcrcsn,n Codc) Any Ciry or Connry which rcquircs r p.nnr Io .onsdcr. .hcr. inrlrove. dcnhli\h .r R ,n any
<br />shcrurc. [i]r ro ih issuric., s rcquircs thc +plicdr f(x such pcflnir ro lllc r siEmd sl .nEnr rh8r h( ur sh. is liccn*d nu(urtrr
<br />ro rhc povi\nnB ofrh. Conkncfu\ Li..n\.d tjw (Chiflcr 9, Commcftin8 wirh Sc.lion 7fiI) ol Dilhi.n I ofrh. Aosin.ss !.d
<br />Prolcsion(Codc)ortharh.orshc tcrcmrr rhcrclion and rh.basis lor rtc slkscd .rcinprn,. An!rn dionoiSNlion?0lr 5i'y3n,
<br />alplicanr fu a pcmii \obj(rsrh. rpplka.r ro a.ivilp.nalr!ornor mrcrhatr livc huturcddollln (S5OO)
<br />l. ,. ouncr ol $c pmFdy. or my c,nplo)€s *id *a8cs as thcn sh <nnpetrsrn,n. will d.
<br />'rE
<br />w..k ,Jd rlf slnri@ is mr
<br />inlcnh or oticrcd for ele (Se ?o14. Busim$ and Pmtc$ions Codc 'l hc A,nlructr'\ t.i..nk trs di$ nor apply to on owrcr .f
<br />rhc rmp.dy *lm boildsor irFmws ihcmn. nd who dG snch *o* hinrcllor hcr$|, or rhro4h iis or hcr own cdDloyccs.
<br />prdviacd rhd s h inprckmnrs m nn inrcndcd u oftcrd for eh. ll howuvcr. rhc FdildirS or irrg)mvcmnr is loH wirhi'r nc Fe
<br />ofcoautliotr. ihco*ncr Auibs will iavc lhc hurden.f[ovins thal hc or shc did
<br />'xn
<br />build or impmvc rhc pmlcn, for rhe plrlne ot
<br />_1,!sosncrofrhcl)(rrcny.aDcxclu\ivclyconrrdingsirhlicdisd..itrrcrrstucon$rucirhcpr.jcr(Scc.70.14.B\in\r
<br />md Pi.lissbtr C.dc lhuContrctor's Liccnsc Lowdocs norrrnlyro ano$ncrolnropc y sho huildx.rnnrtorcs rhcrcor.
<br />lnd who conrrich r'or slch pn,jccr\*irhtrCo kact,(,liccnrd puNudir r.rhc('nl,0crn's l,iccnsc bw)
<br />-l
<br />rnrcxc'nfr un{l.r Sccrnr .R &PC turrhsr.rn(l
<br />Dale: O*r.r - . -
<br />u!)8tr[8S:CqMSiNrA.rrAN
<br />DECIdIAIIO!
<br />I h.rct y affirh rhd& Fnalr, of Fjury onc of rh. following ddh.arionsl
<br />_l hau md will EinrJn 3 C.ni6.ar. orcon* r ro S.lflnsur f{tr workc6' conrp.nsrrion. $ Ill)! idcd itr bt S..rion 1700 of rhc
<br />tihor Codc, tor thc Friommc ol rh. sork for which rh. rErmir ir i\\ocd
<br />-l
<br />hd c , nd * ill mom'a,yq.rlcr' conncnsrnn 'n\uHft., rs (quncd by sc.Lon :1100 of lh. tibor Code, nr d. pdr.mEm or
<br />,h- *, 1ln' {hiLOr/6/ '\A\u{ ir} so'tc^',9o{rn\Jr'on r.{uBirc cJrrcr nnd |.lic} numtquc
<br />.*,,, - /hurotqr..t '/4au+7
<br />{, r\ b t!..nrc $'lrt.cr ri, rtu workys .oo|tn{ nn, Lx*\ ol Cxlilnnnr. rd(l r!'rc rl r I I st{ li h.c.m Nbj.cr t, rhc
<br />$rkun conrltrtr\rliinrpnvi\i,)n\olSrcri,nr:17({.f rhcIf,l$Cotl..I
<br />WARNIN(i t-.ilrr r' sr. workcN'.. rrcnsnrion corcrr8c r\ u rn cDfk,rr t) (ri i'rnl tf,inlriu\ rtrd
<br />.iril fitrc\ un b onc hu rcd rhousand dollrs ($l(i(,.. damgcs as !n,vidcd lor rhc
<br />I hcmhl rlftnrrn'l.r prmhy ol pc,jury rhar I rnr cr 9 (connmncin8 *irh S(rion 70Ol)) orDivisioo l
<br />ot rhc Bu\in.$ d PRntsion\ Codc. r'xi nrrliccns is in rull f.r.c 0'ld
<br />2
<br />I hcoby arrm u.dcr p.ndtyorpcrjury thd ficrc is acotrsrudion kndina llcncy r{r rhc prrornuhcc orihc Pork for whichlhh pcrnrir is
<br />nsucd (S.r.:1097. Civ C ).
<br />AXTLICANLDIIIAf,AIIA!
<br />I hdrrry,fim u ndci r.naky or r.rlury ok ol rhc lbllowin8 dNlarations:
<br />Demolibn Pernirs Asbcsro\ Norifi.arion Fcd.ral Rcguhion{ (Tirlc .10. Pd6)
<br />-Rcqtncd
<br />kiicrolM ificdkn
<br />I cc'rifyrhsr I hk rcJJ rh,\nffli.rri(trrdkl cotr.cr l lgra h .onlply $ iih rll Ciry rnd Counry
<br />prc{nunc\ olrhis Cirt rnd County ro ctrrcr utx)n lhc
<br />ahovc mntioncd pm!.ny lor n *,.,'?-PZADpli.{trlor AtcnlSi*nnlu q 5 -6
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFEFI Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq d/tr /t*A/t/a/]/A-/e---
<br />Shear Wall
<br />Framing
<br />lnsu lation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handi cap Req
<br />Deputy Final Report
<br />Engineer Final Reporl
<br />FINAL to/x//^*'errylor:7,l/rtt,--
<br />Certilicate of Occu pancy
<br />Notes, Remarks, Etc
<br />Flood Zone Certif .
<br />:::w:')ry,:2y.
<br />Lcndcr\ Addrc$
<br />-l.enifythal
<br />lh. i.dcral rcsulari.n\ Esodins,\hc(or rctrx,valarc nor nptli.$lc ro rh,s Imj$l
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