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SITE.WORK DATE ID/SIG.COMMENTS oWNER AUILDIIR DTJLCARATION
<br />I rrrbt ,rfinn u .r pcnalry.l lcrlury rhrr Lm cxcml from lhe Conlrrcron l.kens ltrs r(tr rhc r.lkr*in3 rclsn (Scc.roll.s
<br />Busircss a Pdtsion Codc): Any Ciry or Counry shich rtqotc\ tr p.nnir lo.otrirucr, {llcr. nn['nvc. d.nx,lish or rcPln 8ny
<br />ntocruc. pri{nro ils t\rErce. nlso r.qut s rh. +pli r for \u.h Fnnn ro filcn si8rcd (lremnr rhri h.or sh. h liccned Pusurtrt
<br />ro rhc previri,rns of rlr Cotrhclofs Liccnsd L€w lchlplcr 9. Con ncncinA sirh s..rotr ?Ox) oa Divhion I ol rhc Busincss lnd
<br />Pdt$tnrs Code)orlhar h orshc i\cichpr lhcrcfromrd rhcbr\i\ rrtr rtu rllcecd cxcnflion. Any viohrn,nofSftri{,n70.115 by iIy
<br />rppliclnrar ar--rnrirslbFcr\rh. lptlican o, civ,lpcnalryornor fr{c rhin fivc hundrcd doll$ lS5Oo)
<br />l. as owncr of lh. t'oFny, or nry cnDlolrcs silh w.8cs as lhcir elc .onpcnlllion, wiu do trt wor* ud tr strEl8 is mr
<br />intend or oflcrcd ior slc (S( 7044, Busims! and Pmfcssions Gxlc: ]-ht Co.tacror's Ltcnsc L€w docs ool alply ro d ownf of
<br />Ihc tmpcny who buikls or imp$q rhcmn- and *ho d€s s*h *ork hi'n\cllor lrrsclfor rhmugh hh or hcr owncnDloyccs.
<br />liovidcd (hrr tuch imfmvcrns m mr inrurlctl tr oltarcd for {lc lf. how.trr. rhc hnilding or nq,mkmnr is $H {irhin nN }tr
<br />of.orpLrk,n, rhc OwEr Buikl& will hrvc {h. bur&. of lovinB rhlr hc or n\c dii mr t{il(l or in{,mvc dt Fottdy for rhc N4xN of
<br />L as owncr ol rft ln)lxdy. nn erclusivc)y .onkrrins sirh Iic.trsc'l conrrrct,n k, con{d.r rrr l)oirr (sc 70{,1, Busmcs
<br />,nd P'dlisin C.d.: 'Ihc CodrkbCs Li.ctrsc Lap des nor aplrly ro 0nowncr ol proPtny who build\ or improvcs dc.con.
<br />ond who co ftcts lor such lojccls with r Conhclo( s) lien\cd pt^lanr h)rhccontuct, sLtrcnsc f{w).
<br />-l
<br />mcxcnrDt undcrsdion-, n &PC nrrhi\rnn
<br />O*ner
<br />tll)aKE&)raMflNs^llaN
<br />DECI.A.SAIION
<br />I lrtob, dflirrn undcr !.nxlryoi t 4ury o.c ol rh. followirB d..lnrntions
<br />lh.tcdrdwillnDimainrccdificalcoiCotrsfiloSclfltrsurctnrwor*en'comf4osarion-asrbvidcdlorbrScclbn3T(xloilhc
<br />Lsho, Cdc. ln lhc pcrfortuicc of rh. sork ror whi.h rhc Frmi! as issu.rl.
<br />! hrv.rnd willnBinlrin workcrC conrp.nsrrio. insura.cc- 0r rcquircd by Scdion l7m of rhc bhor Codc. for thc psnrnunQ oi
<br />rhc sork ior qhth rhispcrnrt is nsu.'.1. My workrl .on{Ensrr ion ir\urrmc carir :url Fli.y nun'bcr ec:
<br />tdlv n,.r'"
<br />-
<br />Qffi,n -,***,ntutuc or,hc worr,or *htrh,hhrrrm, i\ x.Lcd. r"h
<br />- aJZs ro b(rrm \ub.rt ro r\c wnrldi.nma(n.sri,,n la*. olcJl orNr,0nd 088. r
<br />rllnoru Dhy8nyp.r$tr in rny manner
<br />hrrllr dnrld bcconr \uhiccr t,rh.
<br />*ortc6 la,nrpcnsrrion porisi(,n\ olS*rn,n:1700 olrhr tf,trtr Cdlc.I \hnll. ionhwilh c.mDly wilh rho{ F)lknJnr.
<br />WARNIN(;] F urc to surc workcn' mn{'cnsalion ovcrusc n unhwlul and shall \xbj.u m ctrlt'lo]tr ro qimirrl pculrics and
<br />.Nil fin$ ut r. otrc hundrcd rhousrnd dollm ($l(x).0)0)iri,,, ro rfu coi ol .ril|)cn\rhon. drtrracl r\ fni!i,l.,l 1,tr rhc
<br />Sc.hotr 1076 oftlE ttrhor Codc. inlcrc( md lrrorrey \
<br />( n.r",a l
<br />DIC|ABAUA!
<br />I hcrchy rfirm undc, ncnalry of prjury ltun I am li.cns{ und.r pmvision of Ch{t cr 9 (commnc ing *irh Ssr bn ?o0o) ol Divhion .l
<br />of lhc Busift$ lnd Prcfc$n,ns Codc. ud ny liccnsu is in tuu fore tnd .nccr
<br />kr-t*"cr"*,l0 Lo
<br />YD*",o b a,-"rX
<br />IANIIAIqIONTENDINC.&AINgI
<br />I hdrcby ftlrft urnlcr pcnallyoflcrirtryrhal lhcrc i\ a c.n(ruclion lcnJirg sg.hcy f.r rl[ l.rionuncc ollhc $ork i{tr which rh( Il.rn r i\
<br />i\\kd (Sc. :1097, Civ C.)
<br />ATIUCANLDECI/Ad.II!]N
<br />I hcnby lnnr ufldd p.tr0hy of pcrJury onc olltc followin8 dechrorions:
<br />Dcmolirion Pcrmirs A\tE os Notili. n r kd.rtrl RcSultrtions (Titlc 40.1'an6)
<br />R.qoired tr(.r of Norificdnrn
<br />[,, \ I (n'l\ rh ric lcdcr]l rcAulaunn\ rsud'np a\hc{n.'cn \rl J'c ior rmlxahh ro rh6 f ol(\r
<br />[#d'b rhrr I hrw rcad,hi. onnlicrrnn and nr,c,hJr rhe abvc inftr.s.on i\ cor(r. l!8re k'com,rlysnh,ll cirysnd counry
<br />\tdma ccs3trdSroELIwsrelnunsrohuildin-!("nnru.ri,r",a.xltcrcbr rh.rD. r.f,c*.t{rivcs ollhis Cilyand Couryro cnln utbn dE
<br />.h)vc rrflnd |not)cnylor iNNclion
<br />Appli.anl.rAg.nl Sigtrol *,.,ahtltt?<
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Rool Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Exl./lnt. Lath
<br />Brown Coat
<br />It4asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL AU,"0 \-/u\N \6L<YY
<br />Certilicate of Occupancy
<br />Notes, Remarks, Etc.
<br />4
<br />BUILDING. INSPECTOR RECORD
<br />4E6$L&L
<br />I 1,.h'' \"'nr
<br />--+-
<br />I
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