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SITE.WORK DATE ID/SIG.COMMENTS o\YNI]R BUILDER DI]LCA RAIIoN
<br />Ihcrchyrlrirnru dcr pcnrlry oI lcrjuy rhnl I N crcnrtl in rlE(tn ract,r l-lcctr\c Ir* fttr th. folk,*in8 r. { (S..70:rl5
<br />Ru\inc\r nn(l Pr.fc$ion Codc): Any Ciry or Counry whicl, rcquirc! r tcirnir n) .o nnid, 0rt$, nnProrc, dcadi$ or rp n rny
<br />itucrm.p!i{rh it\ nsuncc. rno rclurBs rhc {!li.rnr fd nrh Annn k' filc r LiStreil {rrcnrnr rhlr tu or \hc i\ li.cnscd lxnurnr
<br />ro rh. |novnions ol rhc Conrmcroa\ I irn\cd l.r* (Chiflq 9. (iun.n.nr! wirh sccrnri 7(xx) .i Division .t .f ltu Btrsinc\\ and
<br />rptlicirr.rinDirsuhjc.r!rhcapplt.nrloacivil!cf.h!ornorN,cihantuehundr.ndollar\($5ff))
<br />l. rs own$ ol rhc pmFny, or m, cmployccs with w08cs as rhcn $t compcnslri'nr. sill do rlt loa and $c qtrlurc is ml
<br />iftndql or ori'crcd for solc (Sa.7I)4,1. Busincss and Proic\sions (odc:-lhc Contnckx \ Li.cn\c Lrw des nor.pply lo !r o+nct ot
<br />rh. ptuFny whl hoildsor irVmvcs rh.tun. dd who dms such so* him\.lror hcsclfor Ikouah hh or hcr own cn,ploycc*.
<br />pn,vnkd I har such nnpn,$nrtrh 0c mr i cnlc(l n olTcRl tu silc It hoqcvcr, rhc buikling or impmrcmnl i\ $ld u irhin o'* ittu
<br />ofcoq)brhn, rhc O*trs Buiklcr {ill h!rc (lt hudcD oi provnt llrr hc or lhc dii not $uild or inDrow rhc notcny for !h. puq-* ol
<br />l. r{ oqkr of thc nrol.ny. rn cr.lusivciy .onra.rin! wirh liccnvt .onkacrm ro consrrucr rh. I.ojd (S.. 70,1]1. Bunm$
<br />tr'i Pn'lc$i{ Codc: lheConr,!.I '(Licctrsc l,!wdocs nor llprlyr. anosncr orpn,ncny $ho nuiusor inr0mvcs thcrcon.
<br />rid whn conr.dds nr \xch I,r,j..N silh, contr.cktrh) liccrMd pu(u r r, rhc C.nrN.ls Licctr* L!N).
<br />I rn'.\.n,,n undrr S(r
<br />IY!)BKI:B!:!OII[ENSi LIIa!
<br />DECTA.BtrIIQN
<br />I turdhyrfln'nrndcrprmlry.f pcriuryon ofrhclnlLisir!dc.lnrnr$tr{
<br />Ihnrtnndwillnri'ai'!sorkcr{conlFtr1rriotrirNurrnc,r\(qnncdhySccrior.lT(lroflhcl,aborG)dc-ntrrh.pdlonun.cof
<br />rhc sork n, which rhilFrnrir il issu.rl nly *.r1.^- .onp..\ari{r nr\u r. rcc utricr anJ Flicytruflrbcrsc
<br />I ccnily rhrr in ihc pcrtornrmc ofrhr *ork fff which rhi\ p{flnl i\ n\ucd. I \hrtlmr cn!]loy rny n lson ir rn, nuni.'
<br />q, n( tJ b.om suhi(rr ro rhc qorkcrs. conDcnerion lrws ofCulinmo. and lArc. rhd ifl \lnrtrld c(.otu sDbjd r. rhc
<br />qorkc^ ..mfci\dn p.ovkiotrs oiscri.n S?u) nr rhc Llhtr codc.l drll. ft,nh*nh.on{ly sirh rr(,{ r)vi\i.ns
<br />IVARNINC: I.rilurc ro scu'c workcri.o ,If, \rri{,r rovrrusr i! !trhwrul, trd (hrll sunjccr rn cnrlo)fr lo (jni'ui p.nrhi.( Md
<br />civil firs un lo onc hnndrcd rhou\rnd tlollu\ (51(x),(Xx)). i'r 3ddirn,n r. thc ro\t .l n. dlnrg.s rr I(,ridcd ,nr rhr
<br />s..rnr :11176olrh.l xtxtr(ixlc n.rc{rnddnnRv \Icc\
<br />i-3 zor$
<br />[)I!Ir.!rll9!
<br />I h.tobynift'n undcr p.Mlry of pcrjury rd I m liccn{d trnns fovnion of(l'aprcr I (cofrr'Eins wnh s.crion 7m0) olDivhion 3
<br />of lhc Blsincs d Profc$ions G)dc. ind 'nr li.cnsc is in lnllln(.lidclfc.l
<br />De 5'5 -ut?)
<br />CONEIBIJEIIONII]NI)IN.Q-IICI,XI:I
<br />I hcrcby rmfln tr.d$ lcnilryofpcrjulyrnar rhcrc is a con(rudhn tndin8 l8cnc, frn rhd n rfonu.c ofrhc s'ork lirr shirh rhi\ Frnrir n
<br />i\\ucd (Sc. 1097. Civ. C ).
<br />AIIUIANIDICIAAA]ION
<br />I hrtby dlinn undcr Fn{liy ol pc.jur} onc olth€ aolloving dc(lonln,ns:
<br />Dctu irion P,nir\ Arb. .s Noliricalion Fcdcral RcSulariotrs (Tirlc 40. Pon6)
<br />-Rcquircd
<br />L.rrcr.f Norifi .arion
<br />l.cnilyrhd rhcladcrilr.!u[rioD\ rcgnlnrg a\E((os r.nDvrl ]' r mr rmli(r$lc h rhi\ lx'rt.r
<br />_l.cnifyrhnrIhNcrurdrhiralplicarnnr dnrlcrhn!rh. r,vc i,nannl nr i\ c.rsr. l lgre lo comtly $nh all Ciry dnd Counry
<br />onlnHmc\ ndSrrr.lrlsRllrin!k,htrilJi'igr.n{tu.r(nr. ilhrrrhyau c rc[crnurivc\ otrht ciryand G,rnry ro cnr.r upotr rhc
<br />lltr)( nrnrnnEd |roEny lnr
<br />^ppli.anl
<br />or ,tAtnl SiInrlrre
<br />iLIFF
<br />€ -] -241?)
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathin s
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil
<br />A
<br />FINAL 6,-5"1Y Y.WlU
<br />Certif icate ol Occupancy U
<br />Notes, Remarks, Etc.
<br />BUILDING- INSPECTOR BECORD
<br />Forms/Steel/Holdowns
<br />Pool Fence
<br />_lhlvcuxlrillnhiahinuC.nilic,r.orci,n{rrosclrltrurcnrworkc^.onl8rsarion.aslovidcdhrb}SccriunlT(x,otrhc
<br />tibor Codc. for lhc psfo,nurcc o, rhc sork for shi.i rhc pcrnril h issu..a
<br />titrd.ic AddE$
<br />-
<br />I
<br />I
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