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SITE-WORK DATE COMMENTS OWNIiI' BUILDEN DELCARATION
<br />I hcrchy amrm lodcryenalry {'f p.rjory rhd I d cxcnl,l fron Ihe Cont&k f Li..ns. trw ro. lhc ioltosirs rcosn (Scc.7oil 5
<br />Busincss nd Ptur.\sion Codclr Any C y or Coumy whi.h rcqui(s ! ,).iinit b connruct. ulrs. iryrrorc- dcmli\h nr rFn rny
<br />*ru.rurc. prio. ro ns isuancc.0l$ rcquircsrhc apnlic!fl l'or su.h pcrnir ro,ilc ! sisncd sraremnr rhd tr.rshc ic liccnlcd puNuonr
<br />ro rhe Fnlhions of rhc Conrrictoa\ l-ien\ed Llw (Charrcr 9. Comfto.ing wnh sc.rio. 70(x,.f Division.l otlhe Alsinc( lnd
<br />Ptur.sion* Codc ) or lhnr h.orrhc rcrcrpr rh.rcfro Md rh. basis for rhc rlk8cd cxcmplion. Anyviol.liooofSc.rioi70.ll5bytrny
<br />aptlicanr for opcrnir sunjccrs rht applic,nt b!ci!illcnalryofnor morcrhan fi!. butulhd dolldr (!5U))
<br />-1.
<br />$ owrcr ol thc lm,ltny, ,tr nry cnulo)rc\ \'il! $rgc\ rs thcir lrlc compctrL i,nr. will do rh. e.rk rM llr {rtlu c k ml
<br />inr.'rl .rontrcn itr {L (Sn'. 7([.1, BrsimrslDd Pn,t s\i()nsCodc: Th. (-(n r..kr'sLi.cnsctjsdocs.or.pflrioanowmrof
<br />rhc Dtutrory who huilds or irnDrovcs thcr$tr. ndwhod.cs{rhworkhnnsclforh.^cliorrhrou8hhkorhcrowncmpk,ycc\.
<br />n(,vid.d rld sr.h i'npmvcmnrs m Rn inhnlcd or oficrcd for sak lL ho*ct r. rh( t{ildi'r8 or i,n ruvcftd i\ vrld wirhin.nc r{
<br />.f.onlpLrt)n. rh. OqNr Buill& wiU hr\r rh. hurd. of!tu n! rhd hc or stu did ftn t{lrkl .r iDprnlc rhc pDrcny lor rhc purlD* ol
<br />Lns.wicrorrhcnn,p.ny.ricx.lu\ivdlycora.ringwirhli.ctrt.d..r.ror\hcoll\lrxdrhcfmjcd(Sc.70{4.Bu\i'tr\\
<br />aRl Pmt\{ir Cod.: lhc Conkocro!'r l-iccnsc Lrs docs nor {tly ro in owncr olpnpcn} sho huild\ or imln,vc\ rhdcon,
<br />and *ho coikck fDr \uch fmiccr\ wirh r ftmrebn n liccn{d porsur k,rh. C.*rttr s LEctrsc Lawl
<br />I dlcrd rpr u.d$SL\rio. .8.&PC lnrrhisr.rnnr
<br />IABf,EIII.CAMIEN,SA:I,IIIN
<br />DESAAAT!,N
<br />I hcrcby aflnm under ltcnlltyoipcrjuryorc ot rh. followinB dc.larcrions:
<br />Ihrmr *illnHinfuinaCcniicrrcofCon\cnrhScllln\urtursorkcraconD.n\rri,r.d\lnr!trlcdfdhySe.liur3r(x)olrl(
<br />ItrIxxCodc. ior rhc nc.hnnlnccol'hc work rbr whi.h lhcfcni is n\ucJ
<br />I hdvc rnd *ill raim.in *orkcfl cunDcn$rion insuturrc. r\ rcquircd hrSNn,nlT(x)oIthc Lrti]r Codc, f.rrhc p.rroflnin.. nr
<br />rhc work lnr whkh rhis !.rmn is issuci. Myworkcn oml.trsdion insur cc coricr !.d toli.y nunbcr m:
<br />-l
<br />ccnily lhtrt in rhc pcrr'ororancc oflhc work rhr Nhicn lht ocrnrir i\ nsud. I \hrll noi.mphy itry Pcson nr any nmncr
<br />s. nsro bt.onr ruhjccr t, rhc w.*cn .ompctrsilion lnws orcdliLnri,.ond rgrcc thor ii I shoukl l,cco'nc srhjccr t, rhc
<br />w.lkds co rFnsdrion ,mvhn'trs ot Serio. -17I)0 oi rhc tih, Cqlc. l shrll. fonhwi'h comply *irh rlx,* pk,vtmns
<br />WARNINC: F0ilurc lo sclre workcr'compcnsarn,n covcrrsc is unlawtul. rnd shdll sublc.l arl c.lllolq k) riflrinall4mllts ann
<br />ciril fincs tp tr onc hundrcd rhoosrnd dollaF ($lm.m0). i. nddnnrn ki ihc.oi olc.mprrs.rion. dcDu8c\ a\ pmvnkd nn rhc
<br />S.dion 10?6ofthc lihr Cdic. intcrc{ and aiiorfty\ tucl
<br />IICENIDILCONIBACIAA
<br />DECIAMIIO!
<br />I hcEby affilmundcr pcnrltyolpcljury rnal I u lier$t under po$ioi ofCh,fld 9 (sNEn.i.8 enh Sccrion 7(x)0) ofDivnion.l
<br />ol rhc Burinc\s d Pofcslio.s Cod., .rxt Dry liccne k nr tull lbre and cfid
<br />CONSINIII:II!)NIINDIXC.dIiEI.CI
<br />I hctoby rlllrn u.dd lrtr{lrynl |{ juryrhal lhcrc is u.onsrucrion Lndins rscn.y ntr rh. rrrarrrrtr.c orrhc work fot +hich rhi\ Pco,ir ir
<br />isrucd (Sc. 109?. Cl! C ).
<br />dIIUCAILD&q.AAAIION
<br />I hcdry aninn u Mcr Fnalty oi lcrjury orc of rh. followin8 dcclarllionsl
<br />Dc.Dlirion Pcmirs^sb.{or Nori6. io. F.d.rol RcguLtions (Tnbn0. Pfi6)
<br />Rcqurcd lrrl$ of Noliicrlbn
<br />-l
<br />ccnilythat lhc icdcralrcsuhlionsrcsudins ast8(osrcDn,vrl c nor amli.,hlc ro rhk pm,cct.
<br />l.cniry rhm l h.vc.cd rhis 0pplicorion dld nd. rhd thc 0hrvc inioirnolion h cotrcc!. I lsrcc ft, co.r/y snh,l Cityund C.unr,
<br />ordinrnccsa Sr.rc ll*s rcl,tinB ro huildinS construcrion. o,n hcrch, lurho.irc reEcsiurivcs orrhis cirymd Counly t, cn'.r u['on thc
<br />rh,vc nf,nri,)ncd pn,runy lar i'rsnc.rnr Nrf-scs
<br />Appli(ml or,\gcnl Signotuc: A
<br />tr lt," Hra
<br />D,," tfzlf 2C/
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVl nsu lation
<br />Roof Sheathinq
<br />Shear Wall
<br />Fra mrng
<br />lns u lation/En ergy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It/lasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil
<br />FINAL ').-l-244,k-!-.t:r)
<br />Certificate of Occu pancy
<br />Notes, Remarks, Etc.
<br />BUILDING- INSPECTOR RECORD
<br />ID/SIG.
<br />Liccosccl s: Li.c.s. Numh.r:
<br />-
<br />Drr.
<br />L'nn.' . NJn'.
<br />knd.i\ Addr$
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