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DATE ID/SIG.COMMENTSSITE-WORK
<br />Set Backs
<br />UFER Ground
<br />SLAB Floor
<br />Su bf loor/Ve nt/ln s u lation
<br />Roof Sheathin
<br />Shear Wall
<br />Framin
<br />allD
<br />Ext./lnt. Lath
<br />Brown Coal
<br />It/asonr
<br />Pool Fence
<br />T-Bar
<br />De ut Final Re rt
<br />rtEnineer Final Re
<br />Flood Zone Certif.
<br />I uFINAL
<br />Certilicate of Occu nc
<br />Notes, Remarks, Etc
<br />olvNuR BUILI)!:R Dl:l-(
<br />^RA
<br />l ION
<br />, lrrcby aflto uelcr pcnalry t,f l^*riury rlrl I 3 crcnTr,n, rlhc(in rrch6'Lic.h\.hw nt l[c n'lk,wurg tclvrn (Sc' 70]l'5'
<br />llusnes anl Pn,L\\nr C(ilc) Any C y or counry which rcqui,c\ , !.rnil ro crrnslrucr. rlr.r' mlltrcvc. ncmoltrh 'tr *_liir dnv .
<br />(turru..l*iorlo ns ssu{.c, rt\) rcquncs rhc.pnlicrnr tarru(h Fmnt r,lilc r \i!tr.,jsdt nrnt lhrrhcor sh. n L!t.\c'l pu6unr
<br />ro lhc pmvisi,'nr of rlt Conlriuk, \ l.ircnYd tiw (Clufl.r 9. Commcncr! wrlh Sccrion ?(XXl of Divisi()n .l ofrh' Bu(n'\s 'trrliItolcsr,.r c.Jc) rthalh.orshc i crcmfl thcrclom!n,l llE hN{ ntr rhc.ll+cd.r.hntn,n Anvv!'lari0norseron701l5bvanv
<br />.flrlMrl tur r !4rmir sthjel\ lhc lpplic,nr b , c'v,l Fnnlr y ol nor nnrc rlrn 6vc hutr,lreJ nolh (S5Lx))
<br />l,.s owncr o, rhc,ruIrny. otmycmpbltcs s h wrPcsasrhcir so lc conpcns.r iln. eillnorhc*o .nd rh. irmr@ i" -n
<br />i, crrlclt nr ottarcd lor elc (Se...704.4, Busirc$ rd Pn]lcs{ons CL{c: Th. Cnnkaclq s Liccn( tiw Jocs nor amly h an owrcr of
<br />rh. pmrny whr tuius or it{,n)vcs rhcB,n. o wnd &r\ such w.ti hnnscli or hcr{lt or thnn'sh hi or h.r ovn enDl{'v'6.
<br />poviJ.d rhat such inp$Emnh mr, inrcnldl orofl.rcd tur s!lc. tl hovctr, rh. bui{i,s or nryrdwmnr r $ll w'rhhonc )te
<br />ot ontl)kl$n, llE O*nd au,)ir$ wrll h.E ltE hu.,lcn ol povin! rh.r tE or sic ,lil Rn l[i}J or m{s)rc rhc l,oFny lilt th. Ilqx's of
<br />l, $ owmr oi lhc pnrl] ny, rn.(lusivcly conrra.rin! wnh hc.tr\cd uontmcir,^ tr' cttr\lruct th. loj*t (s.c 7M4. Btrtitu\s
<br />,i l\utssi,n Co,l.: Th. conl!{uttr\ l-iccn{ L.w dcs n.r lPply b an ownc. ol rop.d y slxr brllds or imfoecr rhcrcon.
<br />a.d who .onlra.h tu stclr flojcch Pirh i ConrEcro(s] I'ccnscJ Ncuanr b rh. conracnx s Li.co{ hw).
<br />_l rflcrcnrtl un,lcr Sccl
<br />]rcats!8ggallfENsarlgN
<br />DECLANATION
<br />I herchy a(im un.Lr p.nalty ol pcrjury orc or th. nnbwh3 decLtario.\:
<br />I hsvc Jftt srllnunrr) d C:crlrti.lrc olCon\.m b S.lt_tr(urc lin wo'kc's r.nrfnsrhon. r! l'ovklcd nr 6v S(notr l?lnor rhc
<br />Ii xtrC(x]..nrrh.ltrlanmn.tolrh.wuk liirwhrhrh.P.nn'sr{r.d.
<br />an'l willni .in worken .ohp.nsdri(,n nrsurafrc, as rcqur.d hySerirn.l?(Xlol rlr lrbo, Cqlc.lorrhc NrlornEnte ol
<br />Mv *orkcr' .ompcnsrrion insurecc caricr d Fni.ynumhcr{c:
<br />/
<br />-l.cnily
<br />Ihar in lh. Il..ldnBcc oi th. *otk nJt whih ths n rmir is iisu.d. I shrll nol cmP l()y,ny p.son n' any m,nncr
<br />q, ar(o n .om srbr{r ro lhc w'lts\' comrhs.non hws ol Calilffnir, Md lerc rhlr 'f I lhould hccom sdbJccr b rlF
<br />wor(cr' com!.n\ario,i Pn)risiotrr nt S.chon r?00 .l lhc I ihtr Cr c, I \hdl, l,'dhsilh $ndy with rlnre l)nretons
<br />WARNTN(;: Iailurc r) sccuft workcr' ronllcnsar bn (1,v.tu!. r\ utrhwlll. aiJ drll sut'j(i m.nDkrvcr lo.{ininil Fnalli's 5nd
<br />civrl turs up b onc l,trtrllNl rhotr\rn'l 'loll&\ (tl(x).1xx)). trr lt'liur t) I .( o, ronrrnlrri,xr. 'lr! lcs r! !n)v .J lrtr rh.
<br />Scurbn .1076 ol rh. hl Co{c. itrcr.n 3nd d omy "x
<br />!.1!!Id-8rrrl!
<br />I hcrcby rillrm uelcr p.nalry ol Frjury rhar r anr ri"tn*.I m,lcr l,nlwmi chaf rer I (urmmnc Dg wnh Sccrbn ?OJol ol Dilnio' l
<br />of rhc Bu$ncss and PNa.$o.i C\de. !r.t,.y liccnsc ir n full ttrce -rlclLcl
<br />| /'J-, /4,t ,""",^n",-TT l r v
<br />Ih.rhyrlltnrun'lcrr.ulryolF_4uryrh,rrh.rctra.ln{tucri,nhndinga[cn.vInrlicPcrforfrrccolthe*orklntwhthlhsP'miris
<br />issldl (Scc 1097,Crv. C )
<br />APPLICANT DECL RATTON
<br />I h.Elry n{tm undd pcnalr y or ,crjury onc o, rhe rollowine del{arins:
<br />Dcmoli{n). Pcrnrk-Ash.(os Norirrcrtion f{dcnl Rcstlari$ lTnlc 40, Pd6)
<br />_Rcquircd Lelrcr oa Notifstrn
<br />l.cnil,vdrl lhc tcdcral resuhh,'n\ rcg..Jin8 arhc{os rcnoraldc tur rl|l'.rhlc o rhis pn+!r
<br />I N'r'lv rhI t hrrr.Ilrhs rntl(I Nr artl nrrc ilur
<br />orJ'mn(.s m.l Sr{r.lj*\ (-Lr'N b hurLtre ron(turri,,
<br />rhc dhvc mn)maLon r.dnc.r. Lgd k'n)mPly virh rll C[v rnd Counrv
<br />,nl hcrebyrurhoro. rcJtreutrriv.s dl lhh CrlylRl Counly lo cntcr upon rh.
<br />rlx)Y. dntrNJ floFny li)r n\lt .rotr
<br />BUILDING. INSPECTOR RECORD
<br />Formsi Steel/Holdowns
<br />Erection Pads
<br />t)Khl,6L#fr4Ilr
<br />lns u lation/ Enerq y
<br />Handicap Req.
<br />tu*qttD k00t
<br />L.trJ r'. ,lJrc\
<br />-
<br />^,, \ r4 /16
<br />I
<br />14t
<br />lnlu
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