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SITE.WORK DATE ID/SIG.COMMENTS OWNER AUILT'ER DELCARAT'ION
<br />I icrchy lffirm udcr pcnllry of Frjrry rhnr I m €re mnr rfl'nr rh. G).t,.!o6 Lrcnsc t w for ihc rbllowins rcren (Sm ?1,.r 1.5'
<br />Atrsincs a.d Pn,r.si{'n C.dc)r Ant Ciry or County shi.h rcqtrtcs a tc.rnil to rorstrucl. a,tcr. im0rovc. d.fr,lkh or rcIdk ,try
<br />{ru.rurc. Irid r. ils s{,ncc.,ko Blun s thc,ftli.anr r(r su.h l]crn r lo filc a sisncd sucmnr rhd lr.r shc is li.cn*d punur
<br />h rhc prolisions ol thc Conrrucroas Liccnscd llw (Cnlprcr 9. Con rn.in! *irh sc.rnn ?filo of Division 3 ol lhc Businc\s ond
<br />Pmfc!\ionsCodc)orrhar hcor\hc iscr.nfr rh*crrorand rh.r€\t ror rhcalkScdcxcmplion. Anrvnn0lionoaSccri,nT0ll.5hyaiy
<br />rplli.rtrr toru pci,nir subjcch rhc {plicon[o acivilpcmrryof..r mrclhan nr hundrcddours (55m)
<br />l.ns o{ncr ot ih. lnFny. or nr! c r oyccswrhwdSc\r\rhr'r*rc..nloctr\rti r. Billd.lMworltud lhc{turlN n mr
<br />inrcML{ oroflcrcd ti)r klc (SN.70J-'1. Bu EisrDdPmltsio,r\Codc:lhcCotrtacntr\l.i.cn\.|f,wd.csn.r.Ptlt1o.no*nctol
<br />rhr pml)cny qla, h,inlsor i'nnr.vc\rlrnr,xi(l$hod{f,\ru.hqo'k hi'n\clr.rh.ncltor rhnu8h his .r hcr own cmploy.cs.
<br />Ibvid.drhir.hirnpr.rcmnhmmrinhnd.dorollcrcdli)r\rhllhowcv.rrhcnuiuin8orimpn,vutr.ris\'ldsirhin.tu).r
<br />of$nlpkrn,n. rh. Ostui Buikld *rll hdvc rlE builcnorpmvirA rlrr hc or shc did rr h,ikt.r inrfrovc rhc pn,rdy Inr rh. NtDsrf
<br />I. .s owrcr .f rhc pmpcdy. am cxclu\ivcly conrrrcrins $irh li.ctr{d conrradon b (D{tud rh. ,noicr (sc. 7(}44. aunms
<br />and lbfLssi,n Gnl.: 'I hc Contr.ror's Li.ctr\. t-rw do.s not nptly b atr osncr oltroDcrl) who tJuilds or i'llrovcs rhctdon,
<br />ond *ho conrracts (, su.h rmjecrs wirh ! Conrrrron, liccn{d p!^uor h rhc conh.t sLi.cnstrw).
<br />-l
<br />dNcxcnror undcrScclio
<br />Dd€ O*..r
<br />woRl{r'ts' coNrpFNs,{T()N
<br />DEIIIAAIION
<br />I h.Eby afiirn uidrr !( rlry or Frjury onc ol th. lalk,wirs d..lfttrl ius
<br />_l havc,nd *illnuirraiir Ccnillcarc.rCotr\cnrh Sclr ltrsur rd w.rkcs'conucnsarion..s pmrided lor brS(rnrn]T0Oorrhc
<br />L{bor Codc. for thc Iol'onBncc ol rhc wod( fn whkh rh. pcrmir i\ isstcd
<br />-lhrrandsill
<br />rnnr qorkcr'cotrrpctrsdiotr irNurrtr.c. ns rclrtM hySccrion.lT(xrolrhc ljhorC(dc. f(tr rh. lf,rf.nuo.c of
<br />A)
<br />suol M! workqa .o.r!.nsnrion nsuanamri..lxl plicy nthb.r ec
<br />\\
<br />!L,l (L rr[\S\ iq
<br />-l
<br />ccnifyrhlr in rhc pcri.nunccotrhc sork ar *hich!hi\ p(nnn i\ is\x.{.1lhrll nor cnlloy.0ytc6otr in unynrntur
<br />k, I t, b..d,tu sxbicr h rhc *olkcr' conE.sulion hss .f C!lii(mi!. aDd rsrc rhrr il I \ltr,rkl h..o E subitr ro ttE
<br />qoikc^' cont'.nsrrb. povnions of Sccl ion .1 700 of thc Lahtr Gxlc. I \trll. r.dhwirh co rly wirh thoc F)visions.
<br />IVARNING liiluc lo wurc sorkefi conocnsario. covcrrgr i! utrltwtuL and shtrll suhrtl m cmpL)tr lo simin,l ,.n{hi.s ind
<br />civil hrc\ ut n) oN htrrlrci rhou\n d dollrrs ($l(x).1rX)r. i'l .omp.nsstion, dotu-lcs as povidcd for th.
<br />S..ri,i, 1076.l rh.IrlrtrCoJr i,.r.rr tl ronrL\'\f..\
<br />b\22\\$Ipplnr t: X
<br />DIiCIJf,AIION
<br />Ihcrchynllinnundcr Dcnllryofpcrluirrhrr I a li.cnrd xndcr pmvhion ofCh<cr9 (conmncing wirh Sccri{,n 7m0) ofOiviriotr:l
<br />ol lhc Busincs nM Pn,ic$iorr Codc, and my liccrs is inflllrbrelnd.nc.r.
<br />- q9\7UV B
<br />,.,". 9\2[f
<br />CONSLEII:II()NIEN2INCTIIJIII:I
<br />I h.r.h! dn.r uM$ n n hrol pcrtury lhll rhc.c h n con$n,ciion Lndi',g a!.n.y for thc P,rfornmrcc oilh. $ork f(r shi.h ihis tf,nnil is
<br />nn,.J (S.. .rl!)?. Cn C )
<br />APPIICANLIIECIABAIION
<br />I )L{hy rfitn unrlcr pctrulry oipcrjury otrc orrhc Lu{,wins dcchrniion\:
<br />D.m,lirbn PcnnirrAsh.sos Norili.arion lcdcrrl Rqulnrion\ (,'irlc.l0. Pd6)
<br />Rcqun d Lctrcr.lNorilk ion
<br />l.cnilylh lhc ri{cr!l rcsuklnnr\ r+sJ in! a$.sl{x rcnn,vnl rrc ior rPtli.rblc ro rhis nniccr
<br />Fccniiy rtrn t l,"e rc"a rni*,pp li.rri(,n rlid.rhnr Ihc,bv. innmurion nc.trsr lrl.cbc.nDlywnhrllCjtynndCounly
<br />.'di'rn.c\ rfrl srrrc lrs\ rchrnlg ro huildi
<br />nh]vc nrnri.nd proFny lq in\p(ri{'nru
<br />ion. uxl lErchrrDthori.c rcprc{nrarn6 .t rhis ciry ind countyro cntcr ulx)n rhc
<br />A ppliconr o. Aecnr sisnfltuE:X
<br />Pem,ieenanr{ni,no: x Slotg-tz!!+
<br />D.ie :
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsu lation/Energy
<br />Drywall A\
<br />Ext./lnt. Lath 5"Jt-t6 X,YJ"1A
<br />Brown Coat
<br />lvlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL b-6" fi W.W1t4))
<br />Certiticate ol Occupancy \7
<br />\otes, Remarks, EtcI'No{
<br />AfoEob Y,
<br />BUILDING. INSPECTOR RECORD
<br />l.ndc''\ Addrcr.:
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