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SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILD!R DELCAtiAiION
<br />I h.rcby rfttm undcr pcMlry of Frjury rhar I !m er.nrpr f,om rhc Codt,.knJ Ltcnsc tlw lor lhc followine rcaso (scc 70rl s
<br />Susin.ss 0.d Pr.fc$ion Codc): Any Ciry or Coonry whi.b r.qui6s a Isni! h con(rucr. alrr, imrrorq d.mlhh nr rclJn nny
<br />rrru.rurc. Drior ro ir\ ktumLr. al$ rcquncr thc 0rpli.anl for such F,ni o filcr sighcd sr,rcntnr rhlr tEor she is liccnscd,prFranr
<br />ro rnc lovhn,ns .l tlE ConrEcr.i\ l-i..nrcd Inw lchrpr.r 9. Co aRncin8 *irh Sc.rior 7ux) of oivision I ol th. Busitrcs lnd
<br />Prelc$ions Codc) or rhnr h. or sl.d ir crcnrfrthcrclromand rh. hsis Lr rhc llhg.d.ftmprion Any violorionolS{rhn70.rl.5 hyany
<br />aprliL_n rd rNnnir subjNh lhc applicor ro acivilpenalryor.or fl,ft rhrn fivc hundrcd dolhr ls5(x))
<br />-1.
<br />as o*ndr or lhr pfl,Fd y. or my cryloyrcs $ilh wns$ !s lhcn n,b co rp. er r.r. will do
<br />'tE
<br />wolk arxr rhe itu1m n mr
<br />intcnd.d or ollctud fitr srlc ( Se ?044- lru\incs md hofc*ioas Cdc Thr G,nr &(tri I -icctrr lje doc\ ior lplly lo an owNr oi
<br />rhcnmf.ny lho 6uil{k or nqn)v6 rhc($r. Md qho des suh rvo* hrnrclior hcr*ll or rhfl,ulh his or hcr o*n.nrPlorcc\.
<br />Drcvidcd rhorsu.h imrovcDrnh m nor inrcndd or orcftd foi el( It k)x!vcr. rhchuiuinAor inpn,vcnrnr is sld*irii.onc Fd
<br />or.. OLrih. rh. o*ncr BuilLr will tu,rc lhc hnrJctr or pn,lins rhd h. or \hr d d mr ttrild o. inDmvc rhc ImFny f.r lh. rnIF{ ol
<br />-l.
<br />rsosNr.lrlE prc,[ny, !n.rrlusivcly.ofta.iihg sith li.cnscd connEroF ro conitocr rhc pn,rftr (scc. r(}4r- Bu\i"c\s
<br />rnd Pn)fcssi..Codc'lhc(-onnrcln\l,iccnscl-a*doesnorapplybM.sncrol|r)|rny*hohuilAornnprovcsrhcrcon.
<br />and wh. c. rrcrstur\khFnrjccr( wir[. Coft&to(, liccnsci pur{Dtrri)rh.coita.ror's Licc.\c ljw)
<br />-l
<br />n cxcmpr ufflcr Sccri{ni
<br />la$Ells:!:auExsaflQ!
<br />DECLABAIIA!
<br />I h.rcby afii,nund.r pctrultyol psjury.i. orrhc rollowing dNlar0lions
<br />I hlvc nl * ill mainrdn , C.d ilEarc of Conscnt ro Sclt lnrurc l'or $orkcrs' .om|xn\!!n4 r{ Jmvid.d Lr by Sc.rion l7fir of rhc
<br />bi,or Codc. for rhc pc,Jomft. .f rhc work for Rhich rh. plrn is nsuci
<br />Ilrv.andwillnRifliinf,o.kcra.onFn\arioninsuBncc.r!rcquncdhySc.lonlr00olrhclitYtrCodc.ln.rhcl'crfornlrc.o{
<br />rhcworkfor{hichrhi\fxnniririr{ElMy*orkcE.rrmpcnsarioni'rorai...n cr lni Policy nunlf,r r.l
<br />_l.d'rily rhil i,, rlt n'1,nnrurc. ol h. \nrk T,, \h].h lhn n.r cnDloy atry penon in ait nlnncr
<br />$ n\r)lr.o rr {rhlL.rki rlt *ork.r\ .o |xrrrrirn'rh ill.lnn' J h..onr nLhi(lk,rltr
<br />trorku( .oDt1ctr\rrio r f n)vi!i,,tr\,'l Sccri,tr,.r?(turrh$ilh cofDly $i1h rho* nnrNiotrs
<br />WARNINC: l:xilur. t, {rtrrc soikcc' conrt.nsrrion rn cmnlo)lr ro .rn id.l FDltEs ind
<br />rivil firc\ trn h un. hundrcd rhousnDrl dollar\nsrri{m. drnugc\ a\ tlr.vnld i)r
<br />'hcSrcri{n,.1076nlrltr l, hn C.dc. i.lcrc{ rnd
<br />I hcrcbytrltu uDdcr Ftrrlryolpcrjury rhnr I r r p(,ri\nrolCl |n{t)lrotrnmncinstrirhScdion?U})).f Drni,)n:1
<br />rCon. rnd 'nv lhcn\c is in tulllnreandcffsr 2
<br />a 6 3
<br />,,'" o5-o?-@th *"
<br />I h.n h) xllnn, nJ.r Ir rlry,,1 t{llurr_ rhxr rru. i\ r con{ni.ri{,n !.n,ln! rs. .!
<br />i$ucd (Scc.3l)97. Civ C )
<br />/lttt"L('rt\T pr(r,,\R/\rr()\
<br />I hcrcby rin nndcrlEtulryol F-rjury
<br />Dcnolirio. Pcrmir\ Arbc{o\ Norificrr
<br />RcqrncJ hrrcrorNori
<br />sosrcnbulrrc nollpplicahlc ro rhk l)nrF_r
<br />-l.cdili
<br />rl,r I hrvc rcadrhn storc rhar rh. ahorc inltntun n conc.r I iarN ro conurly wnh rllciryand Counry
<br />ivcs of rhi\ Cny and County to cnls u|rn thc
<br />Set Backs
<br />Forms/Steel/Holdowns t -/+6,)rL\ 5t6:q ---
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Su bf loor/Vent/lnsu lation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL l0 - lt -1y \wal
<br />Certificate ot Occu anc
<br />Notes, Remarks, Etc.
<br />BUILDING- INSPECTOR RECORD
<br />llr pcrlonMr-'e oirhd work fot shich rhh Ic mir k
<br />l.iJ -'. 4J'l'^..
<br />-
<br />I
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