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BUILDING. INSPECTOR RECOHD SITE.WOHK ID/SIG.COMMENTS OWNER BUILDTN DELCARA1ION I h.ichy riiln undcr pcmlry (,t pcrjlry rhal I !m cxcnrfl tunr rh. Conrracl.F Liccnsc Lre ri,r rhc tirllowinE lcasn (SE 70.115 Busirrc\s i,il Prorc*i(,n C(xl.) Any Ciry oi G)unr, $hi.h rcquirc\ r Fnir ro con(tud- rlrcl improve. dcnnni\h or mpan any {tocrurc. lrhrto ir\ isurNc.0ko requtcs rhc.tDli.ml fir \uch |tnnn h fit r silncd qdtrftnr rhdr hcor sh. is li.cns.d pursurnr I. ihc fmvisionr of rlf c(n mcror's Li.cnad lf,* (Chtrntrr 9. Connncn.inA wirh Scction ?00O of Divirion :l of rhc Br\i'rcss trnd I\ofcsionsCodc) orrhrr lEorshc iscxcmpl rhcrclionrnd rhcbi\h fdrhc rllc8L{ cxcnllotr AtryviolnriotrofSccrionl0ll5byrtry imlicdt li)ru pcrmir \uhjccr\rh. rpplicanrrorcivill]cnrhyofnolnmlhrnnvchundrcddolrns(ts00) -l-$osNrol'lhcproncny.o.mycmployccsqithwrlcsa\rhcir\n.otrfcns ion. willdo rh wdk tud rh. nduE ir mr inldrdcd.roftcrcdt)relclsc..T&l4.Bu\inc$trndPrntsionscdclhconnctoisl,iccnscL{r'dmstu'l!!plyr)ano*n.rol rhc Impcny who builds o! irtl)roKs rhcNn- and who docs such wo* hnni.lfor hcN.lfor rhrcuBh ht or hcr o*ncmfloyccs. piovidL{ rh{ such inrovcmnrs m n r inrcnddl or ollcrd for vb li nowcvcr. rnc huiLiins or ilrlmvcmnr is $k *irtin nnc )rrrof.oinLrir. rhc Osmr Bri[cr willhnw rhc l,urdcnoiprovin8 rll lE or shc dii dn huik] or in{'mE dE pmlMy lor rhc lruil!$ of 1.,\.witrorrhcI,flreny,ancr.lusivclyco rrclin8 rnn liccnscd co a.tor\ to construcr l hc prorccl (S( TOaa- B6ins\ rfrl P)lic$i Codc: lhc Conrri(tr \ l-i.ctr$Lnsdoc\N n) rn o$nrr,'lImp.dy slr buinls and *ho conlmclr rbr such pn]cd \ wirh rCo DECIdBAIIAN I h.r.by rmrd under Fnahyolpcrjuryone otrhc followiry d(loi ions: I hnvc ud * ill ruinrain ! Ccnilrcarc ot Conscnr h Scll.rnsurc r BorkcN compcnsariotr. I ,mvidcd rbr hy Ssrion .l?u) ol rhc lrnr Aft. t r rh. pcrfonmncc of rhc work tor which rhc ncrnrir is nsucd. l hnvc rid slll nrinhh qork*J onlllc \rrn,n in\uEncc. rs r.qut.d 6r" Sc(r i{)n l7{x) of rh. l jhor Codr, nn rh p.rtuflmn( ol rhc w.rk lor whi.hrln\ pcnnn s s\uLrl Jllysorl.rf co ,Ixd\ari,n, nxtrrrn( crtr'dr r d tinicy nuhh.r rc -l.cnilyrh3r nr r[c trrloirDrccol lhc sork lnr qhi.hthi( tNmr i\ i*u.d.l shrllnor corDloy y Frn{r in rnynrdnncr \) ,\ t, nltoN sulrl..rk,rhcsorkcn coNncn\di,,n hw\ oi(rlinrnii. a ignc rhll ill \hounl hcc.nE subJ.rr hrhc \dk.*'.otr1|rci\ri{n,nmvi\tr)'sofSc.riml?({)olrh.l,rtrn(irlc.l\hrll.trnh$lrhrcnrly*irhrtxr{pnrri\n,n\ IVARNING: l:rilrc ro arur. $or(.r' ..n,F.nsrlion c'!il fincs up l{, om htrndrci rn.u\r dolh^ (llu) Blnl. rnn nrl {'n}.r rn cnrtlo)!r r. .'l'nirrl F-mlr['\ ] dr rEcs x\ |nrntrJ rnr rh. Codc. inlcrc{ rntlarhrmy s 30 I I hcrclry rnim utulcr pcnrlry.fFrjuryrhd I rliccn{Ju crprovi\ionoiChrprr9lc.n,mn.in!virhS.cri,n7(Xn)ofDnnn)nl or rhc llu\ims rnd Pnfcs\ioosCodc. ud my liccn{ i\ in hlllorcc Mncllicr CI}ISIBI]gIIANIENDIdIj.AGENCT I hcrcby rlltm undcr pcnrlryortcrjuryth.t rhsc is r sniru.ii)n Lnding agcky 6rrh. pcnomuncc orlh. Bort tor which rhh lcrmil h ksu.d (S.. ,1097, Cir. C ). AIPIIgANLOEIAAAIIAN Ilrnhy Imundcrp.nrhy.f pcturyoncurrhclalk,wii8decl dions: Dcfrolin,n Pcrn,irs A\tc{osNorifictrrn,nFcdcrrl Rc3uhtionsl-litlc.l0, Prn6) R.qutcd I.nc..l Ndif*,rion -l ccnilyrhar rhc fL{cmllc8ul0lions rc80din8.+r(os r.mrrlarc tut ltltlicrbh ro rhis pmtccl I r.difyrhl ltuvc ftrd rhi\rt1lli.rr rJ nrr.rhrrrhd xh\c i,xSrN kr.. lrlly wirh rll ciryand coufly Ddinrn.cs and Strrc Ir$rlxlingu sti'lc mnrioncd l)ropcnylor inspccr rcp.c\cnrrrivc\ ofrh'\ (-irt rnd couiry t) cfrrr utx rhr Applifttrlor Ag.trl Siamlure A 3-ANN 5 3a r{ Set Backs Forms/Steel/Holdowns UFER Ground SLAB Floor Subf loor/VenVl nsulation Rool Sheathing Shear Wall l4 Framinq uhilB t\c/at- lnsulation/Enerqy Qlyrryall I EMnt. Lath (/1,6[B apr&k Brown Coat ll Masonry T-Bar Handicap Req. Deputy Final Report Engineer Final Report Flood Zone Cenif . FINAL 1/2,l lrP.-{,/z n ) Certilicate ot Occupancy Notes, Remarks, Etc. DATE Erection Pads Pool Fence L$ Lxnds r Ad&e* - - -T------i-