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SITE.WORK DATE ID/SIG.COMMENTS OWNER BIIILDER DI1LCARAT0N
<br />I hcrcby dm'm untl.r |t alry (,r I'crjory rhsr I !m cxcmtr liln rhc Contucktrs Liccns. tj* for rhc lollowina rca$n lscc.7oll 5
<br />Busincss n Pror.sion c.dc): ny Ciry .r Coxnly whicn rcquncr ! pcnnir to conslruct. ahq. imF)vc- dcmhh or spoi nn,
<br />nruclMc- nrfilo ils issrncc. ako rcqutcs rhc.mli.Mr for such pcnnir t, filc a \igtud {d.'tunr rhar h.orihc ir li..nscd Fx(xrnr
<br />ro thc pn'v(n,r ol rhc ConrBctn s l-i..nscd lrs (Chlnrcr 9. ComflcNin8 sirh Scclion ?IlqJ ol Divkion I oi rhc Blsincrs rnd
<br />Pdtsions Cod.) or rh, tr or shc n cftmrr rh.rcfrcm and rhe basis lor rhc llkscd dcmprio.. Anyviol0rionolSccrbn70115hyrny
<br />lrrlicont lbr i p.nnn suhjdk rhc rflrli.ant r. a.i!ilpenalryolnor h.rc than nvc hundcd {l.llaF (S5ft))
<br />-1.6s
<br />u$trd orrhc prop.flt, (tr
<br />'ny
<br />crtloytcs wirh slses 0s rhcn lot.onrpcnsorion. *illdo tht wrk lnd rhc srtrrurc h B'r
<br />i cndcd or oflcrcd for srlc ( Sc-. 7(}44. ausimss and Pnrrcssi(,n. ctdc Th. C.itacror'r I-i.. * ljw docs nor omlt ro 0n oRn.r or
<br />rhc pmpdy wh) builds or nq'm6 rtuc,i. trnd who des such "n* hinrscrforhcrsclforthmlehhn or hcr own cnlp]oyecs.
<br />provnhl rhar such inlsEnrnN m ftn hbdL{ ff ormd ft,r srh li lnsckr rllf buihins or iolPormnr i\ eld $iihin onc ycr
<br />oI onFlcrion. lh Ow.cr Auildd sill hnvc rh. hurdcn nl'pruvir8 lhot hc .! shc dtl Bn h,ild or in{mE ftc pmltny ior rhc pullns of
<br />-1.
<br />r\ owncr ol rhc |ropcdy. aN crclusircly .onrm.r i'r! $irh licc.\cd onrNiiF b .o nd.r rhr p()j.rr (Sc. 7(l,14. tstrnks
<br />arkl l\d.\ihi Codc: Th. Conrractr'\ I-iccnsc l.!w doc\ tror inrly lo rn owncr iil nrnpcrty lho build\ or nnnrovc\ rhcrcon.
<br />and $no coDlrichlnr uch nmrcll *ith r conrro(, licc *d pu^unr kr rhc cofircrtr\ t-iccnr ti1vr.
<br />lrtrrcx.Dnr un(lcrSc.rion .B &PC f(,r[nrcn{n)
<br />Dale O*n6:
<br />trcBKli&f!aurlNs -tu!I2ICL$AIION
<br />I hcrchy rllnm trtuicr Nmlrr.lttrilrrl otrc ofilr hll,ryn,g d.clirrri,,N:
<br />_lhnvc.rdwillnri,nirrC.dilicdcofConsrnrbSclllnsurclirrworkcrrcorpctrsdnrn.u\tnviJcdlnrbySrctn'n:17(X)ofrhr
<br />Lrtu C.dc.larrhc pc'fonMnccofrhc sod nn which rhc pcrnrir h isnrd.
<br />Ihnvcandwillnu ainrv.rkcrf.ol|1.nsaroinr\urrncc.!\rc+nc{thtS..ri{)nlT0Oofrhclf,horC(d..firrhcp.nnnndirol
<br />Mll\rlr6s't*ret{-.d\Jt .
<br />l i-,o
<br />Iccifyrhrrinlh.Ii..lhrnEmcolth.trork,ir$h{hlhisFflniri\issucd.I\hrlln.rcl|loynyter$trinanynuncr
<br />soa!I'hccorrcarht.rrolhcworkcr(conllcn\.rionldw\.fcrliturnir,an alrccrhrrlfl sh,xld hcconf, suhicr iorh.
<br />*orkcn' compcn\rrionfovnionsofSccrion l7([ f rhc Ubr Cd]c. I \hnll. tun lrsirh .omflt with rho{ [ovi\n N
<br />IIARN|NC Fnilr. t, *.ur. woikcts ..nll.nsari,)n co\crr8c i\ urlaqful. ind shrll \trhj(r nn rnlnl,'rrr n, dnnnkltf,Mlri.! rtrd
<br />civil fitrcs ut ro.N hundrcd rhousand d.llnr\ (SlU)-fiXr. i', rddirtr b rh. co{ otconrpcrsari,'h. drnHgrs rs ftuv cd torrhc
<br />Secrion 3076 ofrhc btn, Cod.. inlcr.stnndnxor yt frcr
<br />Jl'r*' 1 t
<br />I turLl,yrrlnn:uDJor pcnrlr
<br />?fi 1q
<br />DESdAAITON
<br />y urFrjxry rhd I aB li.lnsctl u.der l]'orhion of( naprcr, (conrmminE wirh sccrion 70OO orDilision.l
<br />)f rhd Bu\inc\\ md P&rtssion\codr. aBl ml,liccnsc k h tullnr.c (nl clit.i
<br />B luelat6et
<br />"U;t 1.-1 2U1U con,.sdor L+rdarr<re-
<br />IjANEI.BJ,I(.:IIONIINDINIiIIiINqI
<br />I hcEby nrriu und.r penalrr oi pcrjuly rnar rherc is o sn(rudion lcndin8 rycncy for rhc pc omancc of rhc hrh tnr {hich rhi\ ri(Tril ir
<br />nsuen rs{.1097. civ. c.)
<br />l.odcis Addrcss:
<br />-
<br />tx^t r nn\cd f(,F-nt f(r irNtKri,,,
<br />.\Dlli(nnl .r ,\8enl Sitn lurc
<br />l'€mrilt. nnme ( prinl ):,\,'.,
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/Vent/l nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq o//4//c )L 2fb
<br />lnsulation/Energy
<br />D rywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certil.
<br />FINAL {/aa(r,a\ <a
<br />Certilicate of Occupa ncy
<br />Notes Remarks, Etc.
<br />BUILDING- INSPECTOR RECORD
<br />Erection Pads
<br />It/asonry
<br />AIPIICAILDISIdf,{IION
<br />I h.ftb, alrrn undcr rEnull, ol Derjury onc ol lhc lbllowin8 del.rd io.s
<br />Demlilion Pcnnits-Asbcstos Nolification ltdcEl RcSul0Iions rTnb 4'(]. P.n6)
<br />-R.qlired
<br />L.ller of Mlifrclrion
<br />_I.cnily$ar lh. rrd.hl rcSuldions rcg.ding *h.(oqrehovtrl !e nor aprlicablc r. ihir pnrj.d.
<br />-gaccn-ify rh l hNc Ead rhk opdtorion ohd sarc lhar rh. atsv. inr{,mJri.n isc(,lmr.I r88 ro co.r/y wnh srl c,rrand c:outrry
<br />ordinonas and Slatc l,Rs Ehlin8 to buildin8 condtucrion. &*l h.Eby nurh,iz fttrcsnrali\rs ofrhn Ciryn6d Coutrlylo cntcr upotr thc
<br />S>LlLL
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