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BUILDING- INSPECTOR RECORD
<br />SITE.WORK DATE ID/SIG.OWNER BUIt.DER DELCARATION
<br />I hcrchy.fltnr lErcr oculry,,f Pcrjury rhrr I a .rcnrlr rh,fl rh. Cbntnclon l.ic.ns. hw ror rhc rolown8 rcaqr (5..?0.11.5
<br />Bx\inc$ snai Pn)f.sk r Cdlc) Any Ciry or C.unry whi(h rcquircs ! Fmn (o .onndct, .lrct. inrn,vc. &tu i(h,{ El'rir uny
<br />{ruclurc. I'rktr b ns ssuancc, aho rc'luirs ihe applicanr r(tr surh p.m b lilc . si3rc,l {.rcmnr rhar r. or dr is liucns'j luruanl
<br />b rh. l,rrnbni ol rhc Co.ka.'ois Liccn\c'l L.w (Chlptcr 9. ConMBaci,'! w h Scrion 7fii(J ol Divnn,n I or th. Bxsinc$ d.d
<br />Pnrcsn,i\ codc)orlhri hc orshc ^.rcnDr lhcrcIron lnd rhc hass ror rlfallcgc!crcmtlon. Any riolaiion.rs.clDnr0ll.5 byony
<br />attli..nr lDr a p.mir q,$Jc.k rtc apphcanr b rcrv,lP.nxkyornor mne rhan lirc hunJEd dolld! (S5m).
<br />-1.
<br />r\ owncr ol rh. phFny, or my cnl'n,yccs wfh wasc{ rs rhcr vrc conP.ir Dn. * do llE *rn* {rl rhc nturm tr 'x,n[cfr]dl or .ilircJ lor srlc ( Scc.7O44, B sih.{s mJ Ptnasnr$ C.dc Th. Co ru.tr's l-iccns. ljw lll)cs .ol ipply n' rn own r of
<br />rhcpmlf,n, wln' huld\ dr rnpr)vcs rlrRln.3ril w&, {f,r {rh wrrk lrons.ll.t hcncllorrhnrush hr orhcr.wD c.rlbycc\.
<br />pn,vkl.J rtut such in{hEnrna trrc n inrcn'1.'l or olLEJ li,r slh Il. k,wrki rh. l^riun3 .. improvcdnr i\ e)ld wirtun onc }c
<br />ol !.nr{)lcri,,n. rl{ Owncr lru lcr w'll havr rk tnnicn ol ln)vr3 lhar hc or shc dd ft hliU .r mpmvc lhc ln{qly lo! rhe ,urlx,( of
<br />L rs owncror rhcIn,ltny, am.x.lunvclyco rud$8 w h liccnscJ ronta.rd^ nr consnEt rrE Pn*ur (S
<br />dxl l)ntasv Codc lh.(-,)nrrn ttr's l-i.rn\c l,iwdo.\ norrPtly kl r .Etrc! ol Pr)l}cd y sho btr'lds
<br />rtul $ho .oniBlhtur{ch!tuirhwrh. C.nIn.it(9 li.cnscdpur\trrr roth.contacroi\ Ltcnse Law)
<br />DECLARATION
<br />I hcr.$y !IthrnJcr l..llry dr p.rjuy.trc oilhc lnlbwins iicclimrus:
<br />I htrvc {n,l*rll mrn dd rCcnrfic cofconscnttrSclllns!rclitrworken'conllf,nsdlon..sF,vidcdlnr$yS.c.onlTtDdlthc
<br />bt{r C-otl.. lar lhc pcritrmrn.c ol rhc work n qhich rh. llcrnn s ssucJ
<br />-l
<br />hrv. lnd will nrn .rn workcn dnnpcnsarion muBrcc. rs rcqur.J $y Scd i(n :l7iD oi lhc l,rhor Cid., nlr rhc Pcrbmncc ol
<br />rhc work turqhich(hn Nnnn is i$ucJ Myworkc.s conrFn\rknr rnrrtu.!n,cr el frli.y nunrhrrc:
<br />l.cnrlyrh rnrhep. nrmncr t)t rhc work for sh(h rln( o.irnrl h i\rucJ.I nullnor cnPloyany F-6on inan, hdnicr
<br />$ rsbtr.om \uhjccr loltu wolkcs.omttnslrion hw\ol C$lil,rnu, rhtt rgNihll ii I slDuldt{conc bj.d rorlrc
<br />\rton ttuvsion\., Scctotr lTtUoflhc L.htr Orlc. I \hrll. li,nhw(h comtly wilh rhr{ prcvi\rn(
<br />lur. !) scurc workcF ron[cn\Ii,n,.ordrsc,\ urhwtul. nnd nrll \uh]..r 3n cnDl,ycr to.nn Nl F-mlr
<br />N lrtrtutrcJ rhnrrnJ lollr^ (11 ix n) rlr.o{ ol ()n|r{tr\rrrnl
<br />lit( t,\R \ (rl
<br />Irr,.hy.flnfru.rpcn.hyoi!'.rjuryrh{rIrmliccllc'iundcrtR,vlnonolChaPtq9(!l,mEncm8whScct$nrOO0)olDiliionl
<br />.l rh. Bo\ires aod Pof(sons Co.lc. dxl myliu.ns k in ltll ltr.c rBl.Itcr
<br />Drr.
<br />-
<br />(-onlm(lor-
<br />CONSTRUCTION LENDING AGENCI
<br />I hcrby !flirn utulcr ncnalryof pc.jury rhar th.rc il r sn{rucrion bndm8 aecncy l',)r rhc I.ndrmn c ofihc vork tu which rhi\ 0cmit is
<br />isskJ (sN .1097. crr. c.).
<br />APPI ICANT DE(--LARATION
<br />I lrn$, alimr undc! lEnally ol pcljrry om of rhc t)lbwhg d..l&d ions
<br />Drtuhron P.rnds^shc{os Nolilicrrir FcJcral Re8uhbns (Tnk 40, Pd6)
<br />_Rcquncd k($ot Nrriltarh).
<br />l.cnllyrhd rhclci.nlrcgnl]ri,)n\ rcetrJhg Ah.nos ftrnovrl ir. n.r Jnpl'r lc b rhr f,j..t
<br />_l c.n'lyrhxr llrvc r.xdthn nlplicarion
<br />onlom(c( and Sratc tiwsrcLru3 t,, hurldr'l
<br />xr rIr h. ]ln\r trir,nnrlr '..n).,trnt)Ly1v[[rll([yr cotrnrr_
<br />xhor. trrnri,trir!l l)'otra! nn
<br />ArplicHtri or Aletrl Sirnatu
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsu lation
<br />Roof Sheathing
<br />Shear Wall /,/\
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall a-291"fiwu
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lvlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL ,q)
<br />Certif icate ot Occupancy I , u[
<br />Notes Remarks Etc
<br />-27-l )u o^,A J7
<br />h,lrt C^4L.
<br />\-/
<br />COMMENTS
<br />2-I't-41 v.w"t{)(/\
<br />I
<br />LNnsc Clasr
<br />-Lic.nsc
<br />Nunf.r:
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