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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.COMMENTS OWNf, R BUILDIiI{ DALCARATION
<br />I herchy alfirn nnJer n nihy ol pcrju,y thnt I am excnDl l'Drn thc Conrraclom Licensc li,lor lhc nnk,*inr r.i$n lscc7o.ll5
<br />Busincss and ftoLssion Gdc) Any Cny 6, c(rnry ehich .cquircs a Frnrir r. con{d.r, alr6. inrlm!.. dcmlish '{ m!,tr rny
<br />(n'ciurc. lrior ro ns ksuaNc. olso rcquncs thc lrtlicur ror such Ir nrit lo filc i siBrcd tulc'rcnr lhil tEor shc h liccned plrunnl
<br />h rh. provisn* ofrh. Conhcrols Li.e.$d Lnw (Chnprcr 9, Con.rctuin! *irh Sccrtrn 70(}0 of Oivhion 3 ofrhc SusnEss ond
<br />Pmac$k,ns Codc) or thll hc or shc is cxcmpr lh.rulrom and rhc hasi* lor rhc lllc8cd cxcmption. Any vi.l0lionofSccrbnTO:ll5 hylny
<br />spplic8nr fora pcnnit subjccl\lhc applicanr l. !cirilpcnulryoioot mrcrhan filc hrl\.lrcddolh6 (S50o)
<br />-1.
<br />u( .uncr of thc ro|Eny, or my cnrlores wirh sngcs r\ rhcn sot oNpctrsdiotr. s rll no thc qri unn rhc smrm i\ n.r
<br />i,nendcd or oftcrcrl ror ulc (Sm 7Ol,{, Busines anJ Pmlc\sions Codc: I hc G)ntackr'\ Liccnsc tiw docs ior dJrply r. M owmrol'
<br />rhc pr,tcdy *k) huikl\ or i'rwor$ rhcEr. JJxl *ho d,f,s \Nh sor* hi'n\elfor h.^clfor rhmugh his or hcr.qn cmployc.s.
<br />ln,vidcd rhrr su.h i'npft,vc'mih tuc tror inr.rL\l or oflcrcd fd srk. Il h*ocr. rhc hoildill3 or in{'rowmnl h sold sirhin onc Far
<br />ol.onDbrkn. rhc Ownc! Buildcr *illhlve rhc htrdcn ofroving hd he or \hc dii n.r buiu o, nnprow lhe pDpcny r{tr rh. ruqn{ or
<br />I. nsowtur ofrhc ptutedy. rmcxclxsivcly.onra.rinA snh [c.n\.d .o ntn.k rs b..nnrud rh. pn'icr (S(. 7l)4.1- Busircs\
<br />ond r,rdLa{oo O)de: l hc Conrracrois Licensc Law docs nor.Dplyh !noq,n.r oi propcn, *ho buildr or inprovcs rhcrcoD.
<br />,nd who conrtu B ttn such ptui&k wirhnc.Ma.t.(\) Iic.h\cdN^uanr torhcCo ractols Liccnr L.*)
<br />l.nctc r undcr SNIio
<br />Osner
<br />\I(TRKFRS' COITIPINSATl(IN
<br />DECLASAIION
<br />I h.rcby rfl,fln u.dcr p.Mllyoipcrjuryone oirhc follownr8 dc.hflrions:
<br />Ihavc.rdaill tsinrointrcenifi..tcofconsnrr.sclf-lnsunlorwolkctr Llmncns.riotr. rs provided fnbysecrn,nl7ll0ufrhc
<br />bhd Codc. f.r rh. prfomtr.c .f rh. sork for whi.h rhc pcrnrir is ksu.d.
<br />_lhorcond wirlmon rinworken conrpenslliotr imurnncc. rs rcquncn hySccrion:l?(x)ofrhc tlhorCodc. rd rh. ll(rrortun.c or
<br />ihc work rhr *hich rhn pemil is t$cd M y wortcn .omFnsur ioo in{urrrcc crricr a Fri.,nu'hb.rtrcl
<br />I ccnifr rhrr in rtc !.rtorman.c {r rh. sork fr *hi.h rhk pc.nir is i\su.d. I shrll nor cn[loy rny tE6on in any nrtrm!
<br />s rs ro b(onE subj.cr b rhc workdc conDensrrion laws ol Cnlir(ni(. rnn rstc lhll il I shn'ld hcoE \uhimr io rhc
<br />workcrj conEns ion prcrhions ol Selion 37m ol lhc titn. Codc. I sholl. lnn htr ilh cn.ply *irh rhxc ptulhnrnr.
<br />IvARNIN(; r"ilur '., c.u'. tr'1t,1\ .,{nfrnvrtr1. t,rr
<br />.Nil fiDcs u! ro D. htrtrdrcil rhousarrl d.llrs lSl(Xj.o(x))
<br />i\ unl.*ful. dnl] shrll subjccr nn cmFlorrr !o aidin,l lrohk\ 3nd
<br />io.. da@gc. a. Fmvilcd for rhc
<br />,,"'", 1[t A
<br />L$oi Codc. imcrcn.nd dbircy.s ltcs
<br />IE
<br />DEgdn uQN
<br />I hcrcbylfftm undcr p.nilry.fFrtury rhrr I atu lie \.J u d.r t,ovision ofCh.[c.9 (..mnENinE +irh Ssrbn ?(xX) orDivi\n,n.]
<br />of $c an\incs Md Pri,ftsnrnsCodd. rd.,y lic.nsc i\ id fullnncc Md cff(r
<br />-""*-\
<br />CANEIAUqII}NIEIIIACITiEICI
<br />I hcrby llnrnuMcr pc.,lryolr.ljury rhar lhcrc k a.onqfl.hn lc.dirB iScncy ior lhc pcrformrce otrhc *o!k ttr uhi.h
<br />'his Fmn is
<br />nslcd (Se..1097, Civ. C.)
<br />APPLICANT NECLARANON
<br />I lxntry dnim undr pcndlry of prrjury o.c olthc folloqinS dc.lrr.ri.trs:
<br />Dcmntbn Pfimirq-Ash.sos NoLfi. ion Fcdcral Rcguldrions (Tirlc 40, P0r6)
<br />Rcqrft d btrm.rNorifroriotr
<br />-lcenilyrharrhcfcdcrol.csullrioosre8{rdinsNtcslosrcm.valorcnorxl)plicrhlcbrhisp(+cr
<br />I ccdifyrhd I hnv. rMd rhir appli.0rion axl sdcrhar rh. nbvc inroflmtbn n coftccr I a8rccroconplywirhallcnyrnd Cdunry
<br />odi.lncc\ndSt c tiws rckrinB to brildinB connddior aM hcrcby Nrhorizc rcprc\cnrativcs olrhn Cn, and Cou,r(yro cnrn uNn rtE
<br />r,!c trMrnn'cd J,'onody ntr i'Ipc(r
<br />z\ lh- \t\..-,\l)l,li( or \[onlsij]n rtrrr
<br />(_,,9tJ @tora-A
<br />*," r\ t:lr{
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFEB Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Rool Sheathin g
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Brown Coat
<br />l\4aso n ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL llso Ix .l,A"nrtT
<br />Certificate of Occupancy 1 I Tt rV
<br />Notes, Remarks , Etc
<br />Ext./lnt. Lath
<br />Flood Zone Cerlif .
<br />,r" I g
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