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SITE.WORK DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Rool Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsu lation/En eroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lvlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Reporl
<br />Flood Zone Certif .
<br />)/
<br />FINAL \)tY0
<br />Certifi cate ol Occupancy !
<br />Notes, Remarks, Etc
<br />J
<br />OWNER BUII,DER DELCARATION
<br />I h.rchy 1lflrn unJ$ J,.nalrr,,r Frjury rhsr I rh cr.nfl h(,n rh. Conlrrcntri Lacn* lre ntr lh. n)l['-tr[ r.a!r (S.L'70]1.5
<br />Burncs .,n Pnr.sirn C,i., Any Cily or ClMly *h.n rqun.r . Fml h' .on.lNr. llrcr. impruv.. &m'lti nr RIf,r uy
<br />ituru..,itrn, [r ( r!. rt* r.q!@ rlr.ttllrmr itr rkh Fmr n, ik. iSFJ {r.m.l rh.r h. rlE a lx.n*l Fr d
<br />!' rh. F'rsirnr or rh. Conr*tr'r LEn*d Ll (Ch:Fn 0. CoImmnS w(h S.<tr'n 'rux, dl Drvn$n ] of lh. Bu{E r .trd
<br />l\n.s('ns Oxr.)o,ihrr lrorrhc R.rcmpr llE.homad rn $rss ltrrh. rllcf.J.rcqiNr Anyvxrbrx ol S(ri'. ml l 5 by rny
<br />1t'flk,nrfn.Fnnnrubjeclh..mLcrnlk,rrivrlpcnrlryolnolmrclhdnriv.huntlr.dJnl,es($500)
<br />-1,rrotuorl,rFpqrr.itrmycn'ploFr,h*.&s.!llrreL(!trrEngrDrtlJorltwtrnrlEnBrE!Drlrfrldl qolla.1j nn eb ISs 7),1,1, BuiiEtr mJ Pmf6$,8 C*lc: TIE Conbdd.! lrm* t r&xr n{'lyr.soaBof
<br />rhc F)n ny *hl h{Jrtr or iqNEt rh.ron. .rn vh) diB sh x'tt h,nscll or lERlf or rtren8h hr tr h.r o*n .i4lorc.r,
<br />F,vrl.J rhri rh r{mrcBnt m mr idcBlol.r ofiml for !1. ll tk)wr,llE tlrlry or iryreEmnl B $! vilhin rB y.!
<br />oI rurliHior rlE O*E Bui}lq v l n E UE lul. ol F!vn! rh.r ll q ilE ,]n r, t!i! or dthr 0E trlEly tr 0. |i!Fe oI
<br />_1..\owxrot lhc F)n ny, rmcruluiwlyconr..tm8 wnh h.cns.n conu.(n b NnnEd rh. rn*ct lS( 1!.{. Burm(
<br />rnl lhicrsh C,xj. 'rh€ cl,nrrrtltr s l-rcn€ l-.* JlEs Nl rPtly io {n o*n.. oi roll.dy wto bx iUs nr ml]n,lts rh.t on.
<br />rtul whu (,nt{r lo, skl F,Frs vnh r Ci)nrE*ollr lrnsd puFunr () rtra:onu&ttri fr..s lru)
<br />_l rhcxcmF unr.r Sdt.n_, a & P.C. for rh! E.ar
<br />raaf,rSti_.caufENtallox
<br />DECIAIAIIO!
<br />I lErt'y rrfun un&r FuI, oI Fr4 oE or lh. nnhvq d.Lb.r Dtr\:
<br />Ihavc{dwillrurnr n d Ctn r,l(dlc of Conx.tri h Sclr lnurc Ii w cn (onpcnrllrnr, u\ pn'vklcJrinbySc.rhnl?lx)ofrhc
<br />Lrhn C,rl.. lir rlE tEt)tmBc or rhc slt frtr vhrh lhc F.mil s rsuGl
<br />Ihrvc..dlrll ! .m Dor tcri (ohFnrdr)n mu..rf , .! r.liuu8l by Se r&o 17(D of tlE ljhr Orj.. n, rlr FrnllDrr. ot
<br />thc v,rt ld*hrhrh$ pemllr rsEJ My w.rkdr @rvEnurr,n h$r.B. (uE.rn Fnrynumh.r6.
<br />.**, '<"tc*l e Clmecnsqlion I,r9 fir,^d
<br />",-*,'qoiqi4q -zo
<br />I(cnllylhll$lhc!clhi|ndn(1,lhcqollntrrhthIhlrF,flnlsNn'c,]'lrhlllnlcnl!l,1y,n
<br />\) r\ n' hNom \uhF1h rhc worr$ .onFn\rrtr,n lr*s olCal'nn!. r]rl rrr.. rhar ifI \k{B h.rom ruhF\I n, rll
<br />u,rt6' (of,{Ensrxr. F)v!*!N ol Sct.n !7x) ol tlE bhr C ic. I lif,hvnh.rf,{'ly rrh rb* Ilnrvsrns
<br />l. .d rh.ll sut'Fr o orphF (' ('rtlwl FDIB.rn
<br />!r'l fhcs !p h orc lundBj ln,us,!j Joll{r (tlll),fln), r .(Il'rDn , rlr .o{ ol (,mn nuL.n. JIDE s rr Fovrl.d nn rhc
<br />S.(. tr.10?6 ot rhc lrhtr C,rl.. tr ...( m,l imy'\ rcc\
<br />I h.Eby.rrn utulcr Fn.]r, ur tErrury rh,r I dm llr.nsrl !toLr FrvisbnotCh.dd 9(ommBltr8 *trh S{ri'n 7ux)) ol DrvNNn 3
<br />ot rhc Busifts rnd PDLsr)N Cd., ril ny lt.M r o tull 1 .. .,1 .lfftr
<br />3c-t0 ,
<br />0 204
<br />LBby rrum lnkr Fnrlry.r Frlry tlur rhd! !. mdrurion bBrin! rs.Gy tor rlE lEt, m. ol th. u,l ft, whi.h rhi! Fnl E
<br />nsuaj (se. 309?, civ. c.)
<br />&ELTCANLDEqJAAI,P!
<br />I H',.fmu l.r lxulry.rrErnryorc oflhc rolhriry,L.l&.rDn!:
<br />Ir.m,!o. Pctu$Asbdro. liohfrd.n F6Ltl R.8ulxx,nr (Ink 40. Pd6)
<br />-R.q!u.!
<br />Ldlcr ol Niriif,.lrr
<br />I ccrlif, rh.r llr r.aLr.l rruLr,B Erdd'n8 .rtEnos rcd'rd m ft, !ff h.bk k, rhn F,F.r
<br />QL(-nr,t, , r* ." ,*.,'!rkr.n.r,, n.G rh.r trE.,'mn'mri,n K.,rar.l !3Ie 6 oo! y *'rh rU C'ryo! C{!m}
<br />onlmnc.s.nd Srrl.lrws rcl,n! h hu rlin8cDnnturrrn,
<br />dh,vc mntn'k! !n,Fny lor hlFcl0n,r4i,er
<br />rctylutkxur r.FcEnralrvct ol lhn Ciylnd Coury r, cor.r u[r'n llE
<br />Appliu.r or ,tE nr sllBru
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<br />tO
<br />I
<br />IIIIII
<br />BUILDING- INSPECTOR BECORD
<br />I I rt,,
<br />.,"*,- oqlztlzDll
<br />!,.t PAi c A ?J Ll
<br />I.nL.i Atlr!$l
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