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ID/SIG.COMMENTSSITE-WORK DATE
<br />Sel Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />SublloorVent/l nsulation
<br />Roof Sheathino
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlasonry
<br />T-Bar
<br />Handicap Req.
<br />\Deputy Final Report
<br />Enqineer Final Report
<br />/r/a//,r cl uh//lk lcl-'FINAL
<br />Certilicate o, Occupancy
<br />Notes, Remarks, Etc.
<br />(
<br />I h.rcb, atfiirn u c, pcnalry ol lcrjlry rhar I
<br />Bnsircss and Pmrcsion Ccdc): Any Ciry o!
<br />)WNER I]UILDI:R D}X,CA RA'TI(}N
<br />r lcxcDpl lionr rhc Contrnrlori l-icctrsc l,aw ntr rhc ni owirrg 'ci\r (SccTlr'llt
<br />Coutrty which rcqntc\ r p.nnrr r. condtucr, akcr. inllnov.. dcnxni\h i,r rPrtr rtrv
<br />srtucrur.priorloirsn\uttr.c.lkorcqlnc{rhc,rPlicrnllar$.hPcnnilhfilcrsigncdstcnEnrrh'rhcorshdhli'cn*dP!^!trnr
<br />b lhc ldnn,n\ orrlt Conrrrcroas Licctrscd Las (Ch,rr.r 9. (bmtutuing $irh Scdk']n 7fixl ot Dilision I oi lhc Businc$ and
<br />lto lt ssnnrr codc) or r hal heorshc & crcnut lhcrcfonl'nd thc hlsis for lh. allc8cd cxc'nplk,r Any violdlio. oiscclid 70]1,5 by lnl
<br />trlpli.n.( rorrFcmil suhjccs rhc 4plicanr k, trcivillcMllyofnor.brcthan fivc hundrcd dollar(3500)
<br />L ns owncr .f rh. tmtxny. or .r, tnDloyes wilh *!scs N rhlrr slc $np.nuion. siU do rlt wolt ul rh' $nrl@ is fr'
<br />irt"d.'r donard iu;!c lad.7(,i4. B;siness ond Pmrc*ions Codd'rhc Conrracrorl LNnsc lll* do's nol al)Plv b an owncrol
<br />rhc pn,Ilny wh. t{ild\ or hrmrcs rhcn,n, d who dms $cn $(rk hinFelt or hcFcll or lhnrgh his or hcr o*n cnplovccs'
<br />p",,ia.a r t ar sucn inlloEmnG d nor ir cndcd or on'crcd for sah ll hosckr. thc lruildinS o' invsltmnl n *'U qirhin oN Fe
<br />;fconpkri.n. lrrowi;r Builh, willhirc rhc tuicn oiPtulins rl nc or she did trol hui[] or in{mE lhc tmltdv rot rh' pur,'s or
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<br />a\owncrorrhc propcny. ad.rcrusivclyconrlacring sirh Iiccns.{t .o rta.ror lo con{ ru. r rlE lmjc'r (se 7(}14' Bn\in'*
<br />and Pmtaslrn Codc:;l hc Conra.,or's l-i..ns. h{ docs nor,PPly ro 0tr osncr ofptuFrlv who $uilds or improvcs rh'rcon'
<br />und who.oir6cFlorsuchrt)j.cNwirhaConMcn,ntliccn{dP!^udrorhcConk,cttrsLi.cnsclj*)
<br />_l mcxcnrfr und.r Sc.rn)
<br />t).1?: OPn.r:
<br />rvotre*-s' trrorptls,r'rrol
<br />DECIT|8A.II(]N
<br />I hcrcby ufinm uidcr p.tr.lty of pcrjury orc oirhc i,lkrwi'r! dLthrrrions:
<br />lhivcrRl$illnl'inrairir('crrtrk'ofcor{l.Scllltr\urct\rorlc^.orFn\nri'nr\lfrd'{lhrhtSc'ri(rr7(x)olrhc
<br />o,t. ni rh. Ddlannrtrc oT rht \.r[ lnr sh(h rh.lt.rf,ir i\ ^{rd
<br />and willm inuh sorkcrs .on,ncrsdtion itrsutancc. ds r.q{tcl hvsr.rion.ll{x)olrhc l'dhor (itlc turlhc Frrhrnun"'f
<br />r.r which lhi\ Fnrnl t tsuc.i My workcr( coDPctrsrn,n innrnncc crntr a|d Bn icv no 'b'r m
<br />c\DI}D\
<br />Iccnilylhrrinrhct^_rhrruiccofrhcworktor*hi.hrhhpcrnrirl\i{u.d.Irhill0orcilk'vrnvPr'n)nirrnvnufnc"
<br />\i isi, b..oft suht d ro ihc soltcF c.mPctrsdn bqs olClliimi . iN1r8rcc rhd ifI should if,{o f, subrcl brtr
<br />$o ch comNnslri(n,fn,visonsofSccri{,n.r70OolrhcLlhrGrdc.l\hill.hnhwiih.orlv*irhrhosPtorirnn$
<br />lv]\tlNlNe: irdhtrc ro scurc *ork$s ..mEn!ari(,n covcmec is unlr(rul. rtrd shrll ruhi.r arr c'nPht{r b trir inal lci hhs M{l
<br />.ivi1 1n,.\ un b ,trr hnfd.c.l rhousrfd dollx$(Xx)). in nd,l n,n k) rhe .o{ of.o\Ensarion- Jnnucs rs rlovdcd lor lhc
<br />Sccrnn, 1076 nfthc lrhor CodE, inrcrc( $d !r
<br />""'"'4l5ll8
<br />I'ECI.ABAIION
<br />lhcEbyaifirmlndcr0cnlllyofPc'Fry'hallmlielgdu.ddpmvisionofch0Ptg9(conmftnlswnhs.clhnTo(x))ofDivtion]
<br />ol rhc ausimssaid PmlicsionsCodc. and nyliccn$ t in flllfocandcflt'
<br />db,b*",4\f,t
<br />cllllutrl]euQu[NDlNli^li[Nl]
<br />I hc,rhy irfiirnutlcr pcnrtryotpqjury rhd rh;i I cot{rdior tctdirs asci.y tor lhc pcrtnur.c oirhc work tr $hi(h rhi\ Ftnnir h
<br />k$'.,1rs.. 10i)7 ( iv C I
<br />APPLI('ANT DECLAId{T!0N
<br />I M,y llimundq p.trrhyolPc,jlry onc orrhc hllosing dc.lahrion\
<br />l)cnmlirion Pcrmirs Asb.ios Notilicarion Fcdcral RcAul ionr (Tirlc 40. PanO
<br />Rcluircd tf, trcr of NorilEart,n
<br />cenifyrhurlhc LncBlr.gulirions rcAnling r(h.!osrcnrcmldc noi l|Plicrhtu n, rhn frel"r
<br />ti,nr r nd.rhrihc ih.vc inr(,rnnrtr i\cod.cr lrsrsk'conflywirhrllCirvrndCounlv
<br />huiklin!coi(ru.rn .{xlhc durhorizc rcprcefllarivc\ olrhi\ Cirynnd Counry kr cm.r ulxnl rh'
<br />x
<br />,,",.qb1\g
<br />BUILDING- INSPECTOR RECORD
<br />Pool Fence
<br />Flood Zone Ceftif .
<br />Icidc' \ Ad rcs:
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