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SITE-WOBK DATE ID/SIG COMMENTS OWNER AUILDER DELCARATION
<br />I h.nby alfinn undcr Fnalry of Frrury rh.r I n.kcnpr fm'n rh. Conrr.bn- t-i.ctr* h* lbr rhc followins rcrson (Sec.?oll5
<br />llurinc$ md Profc$ion Codc): Any Cily or Cou.ry uhich rcquncs r pcrnril ro c.nnrucl- lllcr. inrpDve. dcmolish ^r rclun rny
<br />{fl.fur.. t rbirs is\rxk.. lho rcquirs rh. lPllica lor slch Ifrhir ro filca\i8ic.l {ar.mnr rhdr hi o. shc $ liccnscd lu6u.nt
<br />t, rhc povtt,ns of lhc Conlracrr's t,iccnicd t 8 (Chuptci 9, ConnftNir8 wirh Sccrn'n 7(t)O oaDivi\idn.l orrh. Bu(incs ind
<br />Pr,r.slions Codc) or rhor h. or shc il crc'npr rhcrclror 6nd nrc basis li)r rhc trll.g.d .rd rrrn Anyviohrn ofsdio.?0115hyuny
<br />rmli.rnr ror r,'.rmi' sxhj{h th. applic.nr io,civilpcnahyornornbrcrh0n iivc hundrcddoll0rs(S5(Ir)
<br />l. rr .wicr of rhc Ftutf,iry, or nry .npkrrcdl wirh warcs N thct (,1. LunPthsrrioh. will do rh. wolk ,xl Ihc n uxrc is nol
<br />irc,xlcd oroficrcd lor erlc(sLr 7(l1,l, atrsircs d Piotcsiiotrs cdlr 'lhc coornc(r\ Liccn{ ljw des nor 3plly k, a. o*ncr .f
<br />rhcin,Fnr_ who hoild\ or i,ran,rcs rhdGnr md wlh d,{s nkh so'k hnn\cltor h$*llor rhmu3h his or hcr own cn]Ploycc\,
<br />pr(,viiicdrhisuchnnprokmn(arcnori'cnd or oficr\t rbr uh lll h,wc!.r, rhc btriun[ .r irrovcnrflr is skl *ilhin oN }!fi
<br />ol cofloleri,r lh.owtrcr Buikh *illttrvc thc budcn oi pfl)vin8lhar lk or shc ln l()l huiu or inDrcvc lhc r$pcny i(tr rht l[qrE or
<br />I.dsowtrdofthcfiolIny.ancx.hrsivclyconrntirgwfhli..ns&l.ofirncrnh.on(ruclihcpmicllscc7(!i.Bt\i"c\{
<br />il lt,frsbn Codc -t hc ConiEctn s l-iccn{ I-sq Joc\ nor rppl} t' ,n owi$ of lfi,l. y{ho buildso. inrplovcr rhercon.
<br />rnd qho conhcrsf suchnml$tswirhaCo tudo(n liL.cnscd runuonr ro rhe o)nrrlcrois l,iccn\c tjv)
<br />I rNcrcnr0 o cr Sc.ti
<br />]rc4tr!8sirlllllNsr[IoN
<br />DLCLANtrT9N
<br />I hcrchyrlfnnund.r|E rlrrol txrj0ryotrcoflhcnlllosil!dc.hrrridr\:
<br />Ldror (-rxh, frr rhr Irrfonmncc.l rhd work frtrwhic[ rhr pcrn,ir n n\!cd
<br />rtrr.,kr:1r\,.t M\q.rt.,.nlyn. i..,i,\r,rrt"t,ri tr,,lT,ti.)idtrFt,... rl/ttLrat (c/*\ :ol".(3r\ rwa-o61d?:
<br />I .cdify rhnr nr ihc NrfornrN..frlr. qork,nr which rhn Nnnir is (sucd. I \hrll rol cnr,loy !try pcrw'n in trtry nrDncr
<br />s r ro hcconE subjccr lo lhc worlcis' co nr pcns! I trn h*s ofC,lirbrnir. rnd JEr.c rhd irl shorld h.co,r \uhjc.r h rh(
<br />*.rk.ri c.npctrsrrion pmristunrofSccrn,n.l?(l)ofrhc lrh.r Codc.l shall. fonh$irh conply wirh rkJ{ |r'risions.
<br />W,\llNlN(;: Frilurc t) kcu.. woikcs'..nlrrs hn .ovrDlc n unltrwfxl. 0M shrll srbj..r u cmploycr ro ri'ni'[ltM]ric\ nd
<br />civil fitr.! up t' on. hrndr.d rh.u\.nd d.llxrs (Sl(X).(XD), in rddinnr ro l[c.o{ of.onpctrsdion. drnr8cs r\ pnrid.d hr rhc
<br />I:-..iui.i-['i-io'rd;::;''
<br />llcElsELCQNrXAstrf,
<br />D&CLTf,AIIIJN
<br />I hcrcbr.lfinnundcr!.n.hyor!.rjurylhrr I am liccn$d u cr pmvhnln ot Ch{nls 9 (c.mmtrins wirh s*rir. 7flD) or Divhion 1
<br />of rhc Buqincarand Ptufcssions Cod.. nlld nrylhcnsc k in tull fDr...r1d cflicrs l.9.n1oo n
<br />J\J V^+<r*.
<br />tlllEr&lcr()IitElDlNclliE
<br />I hcrby.tnrmundcr Fnax, ol,'.rjxry lhal thcrcir.on(ru.rirn L.dinC.e.my lorlhc pcfornr.nlr o{ rhc w. r'or whi.hrhk pcmir is
<br />hsucd lsa.1097, Civ. C.r
<br />AIIIICANLDEIT,AM.IIO!
<br />I rf,rby nnim u ndcr p.n!hyofprrjury onc.rrhc tink'$ins dcclararn,n\:
<br />Dcmliriotr Pcrmits.Asb.n.s Nolificarion Fcdcr0l Rcgul0riotrs (l irlc,10. Pra6)
<br />-Rcquircd
<br />trtrd oi Notifi cltion
<br />I c.nifyrhd rhc fcd.irl rcguldrir.! N8!rdin8 r\h.i.r enbval arc nor.pflictrblc k' lhhrmrct.
<br />2l ccnifyrhlr I iave rcad rhis applicarion lid narc rhar rhc lhore inlomart,n h.ode.r l,sicd!o.omllyrilhallCilyandCounty
<br />ordinanccsand Shrc Llqs rcLritra lo buildinsconsrru.tiotr. o h.Ihoriz.,.n.c\cnlari!$otlhisCi(y dc.un'yroctrrcruDonrtf,
<br />ibiivc nk oi.d popcnv fttr i'r\n .rn,n Nrpo\c\
<br />]\pDlntr lor,\xr lsiln l r.
<br />f'emire nnme rprinl ): PCr -r:,l l*,
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathinq
<br />Framing clL21(y.,(,14fr,
<br />lnsulation/Energy
<br />Drywall
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />En gineer Final Report
<br />Flood Zone Certif .
<br />FINAL l'/4*ar >A68
<br />Certilicate of Occupancy
<br />Notes, Remarks, Etc.
<br />BUILDING- INSPECTOR RECORD
<br />\.r.la
<br />-' .t ;:r 1(.
<br />- i 1lJ l0
<br />Shear Wall
<br />Ext./lnt. Lath
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