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SITE.WORK COMMENTSDATEID/SIG,
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Roof Sheathinq
<br />Shear Wall ixwsl4 'zD)Framing Rhg n
<br />lnsu lation/Energy UI
<br />Drywall 7t :2,t)
<br />Ext./lnt. Lath I u,
<br />Brown Coat
<br />It/lasonry
<br />Pool Fence
<br />nlXrrniT-Bar )tflN'rq\7u
<br />Handicap Req t u.r
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certif
<br />I
<br />l-,4fiU,19r'FINAL l(tu-D)
<br />Certif icate ol Occupancy lUli
<br />Notes, Remarks, Etc
<br />OWNER B('ILDER DI]LCARATION
<br />I l.nrcty ulltn undcr Fnrlry {rr rcrJurl rhrr I cxc rl, fmn lhc Conrra.ror' l,iccn\. I-rw Lr rhc rbllowina rcrv'n (sc.70ll 5
<br />Au\inc\\ aiJ Prcf.\snrn Codc): Any Ciry or Counry which rcquircs J nrnnir k, .otr{fl.I. rhcr. imPmvc. dcfirlinr or rcl)an .ny
<br />sd.rurc.rntrrons isuurEc. rl$ rcquirc\ rhc xpplicatrr tur sNh ltnnir ro rilc r stncd srarc'Enr ihar h. .r slr i1 liccnscn runuur
<br />tJ rh. pr.visio \ ofrhc Conticrols Liccned ljw (Ch!!rc! 9- Commch"ing wfh Sc.riotr 70UJ ol Division.] oI rh. Busircs rtrd
<br />PmlcrsionsCodc) orlhrrhcorshc i\cic'npt lhcrclio and ihc br\i\ turrhc rllcgcd cxctrrtlion Any violnriotrolSccli.n'10.115 hyrn,
<br />rmliclnr foru pcn!ir \uhjc.r{rhr r!pli.rtrriorcivilfcn.llyoltrol,rtrcrh fivc hrndrud dolltr^ (s500)
<br />l,$owncroflhcpopcny.ornrycrpl('ydcs*nhwr[c\asrh.ir$lccnmPctrsorion.silldolhc$ork,rx]rh.ntl(uEisnor
<br />inrendcJ oroflarcd tbr qlc (S( 70,1.t. Bueimss.trd Pmlcssions Codc: Tnc Contacror\ I-kcn* uw docs nol apPly ro ar owncr or
<br />rhr pn,|Edy wlx) buildsor iryrolcsrhc@n.uld who dessuchso* him\clforhct\clforrhmugh hi! or hcr own cmployccs.
<br />I]ovidcd rh su.h ituptuvcn.ns m mr irlclrdcd .r ofteBl l'or suh lil howc\tr. thc huihin8 or imProEnEnr i\ R,ld wirhi'r uN ]eJr
<br />of conDtt6n. lhc Os E Buildq will hdw rtr MrdM or pn,vm8 rhd tE ot shc did mt hoild or i,Wmw rhc pruFny fm thc Ptrq't.r
<br />l. r\ owncr of r hr l(,Fnt, ,'n cx.lusrcly conri0crirs wirh li.cn{ conkNtm kr con{ru.r rlr rn(+cl (se 7(xr. Bu'i'f,.\
<br />dkl lhill\\irCodc:IlEConlracktr\L.i.cnscl-rwdo.\n.rrptlybni.strd.lt'rctEnrwh,'buil{h.rnuhvc\lhcrcon.
<br />lnd $ho conrds lor such Itroj.rrs wnh d G,rh.tun, li.ctrrd t'ur{unl b rlt Conk nn\Licctr*I-rw).
<br />-lrNcxcn,pr
<br />un,l.r S..rii,, .ll &PC lnrrhi\'.x{,tr
<br />Dst€: Ovm
<br />wonxr"q-s cot\tPF'\sArI{ril
<br />IIiII.AB{IIAN
<br />I hc.chy !nnd undcr rcnrhtorFrjury onc ol'lh. lnlbwirs dcclffllion\
<br />I hrvcr d *illtrui'nrndCcnill.rlcolCon$nrl(' Scll ln rcftrsork.rsco rt{r\irior.ir nFvidcdrorhySc.LotrlTfi)olrlr
<br />lrtxn C,)dc. turrhcltrfornr ccofrhc *orl lorqhich rhc Frnir i\ ns'c.l
<br />IhvcrdsLllmrnrlt*orkers'.onfcfsnnnri'Nur"n.r,rsrcqtncdhfSc.ridrlT(xr.lrltl-nhorc()dL.latthcFnn'ND.col
<br />ih. utrk lor shi.hlhh p.nnir is i\ .rl l\lyworkcA Co ll.n{r n in\urmc.Micr {l|r,lEr_ trtrn$(r dc
<br />-l.cnllyrl
<br />rirrhcpcnn',nrncc.frhoworkfGwhi.hrlrh|.rnrir h i\srcl- I \hr ll nor chPht any Fron ir any Nnncr
<br />v' r\lo hccoN subjcct t,rhc wolkcliconlEns nr he\ .i Calilrffir 3ndrsr.rh i irlshouLl bc.onE suh,c.rt,rlt
<br />wortcr! conrrnuii.n tn)*ion\ olScdion 37mof rhc t-lhtr Cnde.l\h,ll. rifhrth..nuy [irh lh]E pro!i\i.n\
<br />WARNINC Fnibrc n, sdcur. w(trkc6'.ompcns or covctnsc rs utrhwtul. xfd ndl $bir.r rrr cnDroys r{' cn'nirdl Fnrhics rM
<br />civil tirc\ up t, onc hund'.d rh.u\rnd d.lli^ lsl(x).Ux)). in rildirion t, rhc coq ofc.m|xtr\rrion. damsc\ ri fiovidc ioi rhc
<br />Sc.rnnr.10?6ofrhc libor a c. irrcrc(.nd allorncy's iccs UL,!d9ras
<br />IlLELtlUllOl
<br />Ihcrcbyrfinmundcr pcully of tcrjury rhd I rr li.ctrk{ undct t)n,vGionorChalrcr9(c. nrm.1ng q hSari'n7o0o)orDivrio.l
<br />uf Irc auvm\slnJ Prolcsion\ Cd.- ud nryli.cn{ i\ h tull ntr.c rnd cffcd.
<br />b,t
<br />o"", 1-r}-\6
<br />CI}NIIBIJCIIANIINDIN(jA{jIICI
<br />t h.rb, ainn! lndcr Fnrlryorp.rjury rhnr rhcE h n cotr{rucrion lcndin! lgcnct rrtr rlt rcrroilrmcc olrhe sorl ror whi.h rhis lcnnil is
<br />hsucd (SN l(})?. Civ. C ).
<br />AETUCANLDECI,A3AIIAN
<br />Illa$y lrD undcr |rnlh y of pc+ry .ic of thc f,,llownr8 dsl.fl i{,tr(:
<br />D.molirion Pcrmits-Aslic(os Noriri.arioi FcdfalRcgulrrions (Tirlc40, Prn6)
<br />-Rcquircd
<br />t rrc.oiN.rincarbn
<br />-l
<br />ccnifyrhd rhc rcdurdl rclxhiions rcsrdin8 osbc$os re.rval lrc nor llprli.ahlch rhis fmrccr
<br />l.cniftrh I havc rc.d rhirapplEarion dsrlrcrhrrlhcrho\cinnrh ion is.orcr I agtt ro otnPly wirh rll Ciry and Counly
<br />ordi'rri.cs nn,l Srrrc Lrws rclalin3 lo building consltucri{nr. od hurchyaurhtrizc rclrcsnhrivcs ('alhi\ Ciiy aid Coutrry ro cnrcr uF,n lhc
<br />rlx)v. nrtrri{nrll fn)rny nn risJnrri(nr
<br />/\Dpli..nr rr Atont sigtrrtur.w\-/-
<br />\!,..H
<br />*. Q-rg- t6
<br />IIgKm
<br />BUILDING- INSPECTOR RECORD
<br />UFER Ground
<br />Sublloor/Vent/l nsulation
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