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SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcr.b, aflnm undf,c.rhy ot lErjury rhlr I un cic'npr frtnn Ihc Coffacn)n l,iccnsc tiw foi rhc rolbwing.cr$n (Se7011.5
<br />ausincs d Pxrlssion Codc) Any Cny or Coxir! which rcqutcs r Frnir ro .onqdct. trlicr. imrrclc- dctrblish or rc|oir rnv
<br />srrucrurc- llntr b irs hsunncc. trho rcquncs lhc applic. tu suchricrEir t, filcasiSocd stotcnEnr rhtr tEorshc h liccoscd PuNUaol
<br />lo rh. pmvnions of rhc Conl,act, s Li&ntdi hw (chlprct 9, Connmrcing wirh sc.rion 7O(x) of Divhio. I ol rh. Busincs 5d
<br />Pft,fc$ionsCodc) orrhnr h..rshc is.rcm lncrcho md rhc h$i\ futhc trllcg.tcrcmolion Anrvi{,l,rionolScdionT0ll5hvaiv
<br />nmli.anr fofu punnn subjccb rhc urplic0nrroa.ivillcinhyofnornlorcrh fivc tt.drcd dolltrs (5500)
<br />-l,trsosturorrhcpmFny.ornrrcnlloyceswirhw!sc\u\rhctsoLcotrrPcNalion-silldolhtw.rksvlrhc(rudurcisnornnctrdcd or .iT.rcd for sL lS( 7OlJ. B$imss ,id Pmlcsrions Codc: The Qrnhcroi's Licctrs t!* docs nor aptlv L, t, osrcr oi
<br />rhc pmp:dy who bxilds nr iDImKs rhcG,n. dd wh. d*s such woft himscll or hcrclr or rhftulh hk or hcr oNi c nlovccs.
<br />pnvidcd rhal slch iEpr.vomntnEmr inlcnh Moflscd forsak.lt ho{cw. rhchui[insor i'rotuvcnrnr issUsnhinotu )t,
<br />ol.onplcliotr, ttE Owncr Builds {ill h!\t rlr burd.norpmvinS dd t* or shc did fr, huiu or nlll,rorc lhc l,Dpcny f.r llr PU{F$ ol
<br />l. $owncrollhc nmncnr- a'ncx.lurircly.onrr.rirrS wirh licotrrcd conlhcttrsro consNcr lhc pmlccl (Se.7lX1 ausirc$
<br />and Pn,is{rn Codc: Th. Conr,.rols Liccnse Lrw d{Es nor ryply b an osncr of[opcny wh(, builds or irproles lhcrcon
<br />nnd who cunkNrsfor such pmJc.k rnh r Contr.ro(s) liccDscd lurunr t,rhcContr.t \ Lacn$ Lls)
<br />Lft.rcmB undcrS.cli,,
<br />Dotr: Owmr:
<br />woRxrRs' colllPENsll loN
<br />IECLAIAUAN
<br />I hcrcl'y rfitni uid.r pcnalryofpcduyonc oflnc n,llosins dcclniarions:
<br />I hrvc drd willnridrin a Ccn ifrnr. ot Coh$fr ri Sclllrsurc l'or worlc'i.. rPctr{dnr.01 lDvided fttrhySc.tion l?rr0olrhc
<br />l-xkr Cdq fn rhc p,rloiiMnce olrhc {o!* for whi.h rhd p.nnir is ssucd
<br />I hNc. willnuirrrir *orkcri romrcNir llyij'",#;li rcquncd hySc.rim.17lX).irhc tihor G)dc.lor Ih. Fr,ormhcc of
<br />i,,n inluBn.ccrnicr lnd Ix,lic] trutuh.r ricrhc uqk br which rhi\ F-nnir i\ '\sucd My
<br />I..difyrhrr in Ihc |.rioflBnccorr[c ntrphi.h rhn lijnni h n\!cd,I \hrll mr cmploy any Pcr{nr nr rny mtrnN!
<br />n' is n, h.corr \ubjc(rki rhrrorkc ion hx ol Crliturnir, ,id rBn hll il l \hi,ukl tf,.o.r tuhjed lo rhr
<br />wrkcr( ompensrrion pDvirions .f SLlion 3?(x) ot rhc L5bor Grlc. I sh,ll. fonhwirh omPly sirh I ho* ,mvnions
<br />WARNIN(;: Ftrilut n) surc uorkcrs conll)cn.rrion ro\rrr!\ utrliwful- !!d \hdll subj.rr an cnrploycr
<br />'o
<br />dininrl lrnrnts ond
<br />ci\'l ftrc\ trt tu orc htrndrci llou\rtrJ doll rs rJl(n.UX)). r ior r{i rhc ..i or.otrrcnsalion, datus.s ds Providcd tn rh.::::[/aE
<br />!.1!!!"I&IIII.II
<br />I hcahy ofinn uftlcr o.nlliy of lcrjury rhar I {,nlicetrsdutrdcr tr^N,ri'lrchJl,lcruio nf,rc'nC* hS.cri, ' Tl,txrrof Uivirnr:l
<br />u|hc Bu{n.{. trnd Pmlc.\.on.C '1.. Jd \l.cn\'F'nlullrorc.ud.lticr
<br />\,,/
<br />AIELIIANLI)LEIAIAITO!
<br />I h.ftby dfln'b undcr p.nrlryofpcrjury.ic ofrhc rollosing dc.lff0rions
<br />I).mlirion Pcrnir\ Asttnos Norifi..tion lcdcrtrl Rcsuhlions (Tirh.r0, Pd6r
<br />-Rcquncd
<br />L.llcr ot Norirt.rk,tr
<br />I ccni8rhdrrh.,cdcrrlrcAuhrnrt\ r.trd ! Nhios rcnxrvrl rrc nor lllicrhlc nr this Pnrlccl.
<br />odi',anccs Md Srarc tlwlrcLfin3lo ldinEcon{rucri,,n. {lhcrcby rurhoriTe rcpr.sc.urivcs otrhis Ciry and Coonry ro.nrs upo" lhc
<br />rhovc nrN i,rE,l I,' o|xny lnr jlzzlze
<br />^*-7 r>2
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/Vent/lnsu lation
<br />Rool Sheathino
<br />Shear Wall ,.<\
<br />Framing lo-z-lK V.\U^U
<br />lnsulation/Enerqy u \:-/
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />l\4aso n ry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />/A
<br />FINAL 'd-29.1(k-v/JA)
<br />Certificate of Occupancy
<br />Notes, Remarks, Etc.
<br />BUILDING. INSPECTOR RECORD
<br />Pool Fence
<br />Flood Zone Certif .
<br />------)_--
<br />7//A
<br />IOIiIBUqITONIENDIIIGIIENCI
<br />I hcrcby otfirm under rEtulry of Frjury rhal rlrrc h s clnslru.lioo kn<li.gagctr.y fotrh.p€ otmee Drrh. work lotshthrhtl'.mir is
<br />issu.d (Scc. 1097, Civ C ).
<br />L.1dq\ \Jmc
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<br />l>,
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