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SITE-WORK DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFEB Ground
<br />SLAB Floor
<br />Sublloor/VenVl nsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framing
<br />lns u lation/E n erq y
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />IVlasonry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />FINAL irlL/lt >0 76
<br />Certilicate of Occupancy
<br />Notes, Remarks, Etc.
<br />OWNER BUILDER DELCANA ION
<br />I hcrcby aflirm undcr lcnrlry ol rcrju,y rh0r I !m cxcmtr imm
<br />'hc
<br />Conrrucron l-iccnrc L]* tnr rhc r{,llo*ing rcasn (sc..7orl 5
<br />Busincss and Prof.\sn,n Cui.): Any Ciry or Coumy whi.h *quirs r Jxrmir h con{d.t. rlrcr. nnlo(- dcmlisn or rcIot lny
<br />rrruclur. prior ro irs nsuarcc. lls rcquncs rhc umli(lnr fo! such pcnnir ro nb a sigmd {srcftnr rlEr h. .r sh. is lrcnsd llunuanr
<br />ro rhc pmvisiotrs orltr Conhdols l-iccnscd &w lchalrcr 9. Com,rcNine *ith S(rion 7([X) of []i!ln,n:l orrhe Businc$ rnd
<br />Pmii$ions Code)orrhol hcor shc hcrcmnr rhcrc{romand thc hasis lorrhcllkscdcrc'.prion. Anyliolrrio.drSc.ri,n70rl.5byan,
<br />+tlicaor for 3 pefin subjec( rh. rtplicanr ro ! .i!il pcmh y ol nor mE rhxn llve huMmd doll&s 1S50O r.
<br />I. $ rwmr oirhc pn'Fny. or my cnrployes wirh *,gcs.s rhcir vnc..nrNn\ution. willdo rhc qork und rhc \furm n n
<br />i c'x6.i or onarcd lor $lc ( Sa 701,1, Buircls {nd lt{r!\\ions (tdc 'l hc Codructtr \ l.icc \c l iw d.cs nor lPply lo m omt or
<br />rhcnmEny wh. huild(.r nwtrL\ rhcmn. nd qlh des snch m& hnnsclf.r h!^cllor,hnugi hh or ncr own cmlloyo.s.
<br />pruvidcd rhrr \uch inrolcftnB m n inrc idcd or offcrcJ fr\rh lf.howcv.irhctriklin8o.!\rovcnEnlhwlduirhinonc)r,u
<br />ol3nvlcrinr. rhcOwncr lruiucr $illh!!crhchurdcn.IpDvirr rh:r hcor\hcd ton brild or i'iJnolr rh. tml.ny lorlh. Nrlnsoi
<br />L rs n*nc' oI rhc F)ncn y. rnr cr.lu\ivcly .onrr .ri'r8 wirh liccn!.{l conhd)^ t, coNnr.r rhc tmjN ( Scc 7(,14. tlusrc$
<br />.rd Asll\rirn C.dcr lhcCont&lrtr-r l-i.cnsc t-rwd,{s nor if,tlyh rtrnsncr ol fropcrlywho $uikl\ or im!rcve\ rhcrcon-
<br />rnd who contrct lirr such projccts qnh r C{, racro(9liccnrd plrrtranr ro ihc Cont(ktr s Li..isc bw).
<br />-l
<br />an ercmfl ond.r Serion-, B &PC forrhL r.a$n
<br />D.t., O*n.r
<br />]}oatr!8s:1:0llfENlarlo!
<br />DECI.AA^I1()N
<br />I hcr.htrflnnondcrI[ hy.fDluryoN.f rhcfuik'aingdc.harnrs
<br />lhrvc,ndsillnuinrrinaCrtri,l.dc.fCon{ r t, Sclrln\urc f(r sorl$s .onlJ}-nsrri(nr. is Dmridcd tu bySc.ri,,n:1?(xrofrhc
<br />trhorGxlc. f rh. pcr nmrmc ol rhc*ork f(tr qhi(hrhc r.rnrir is i\sucd
<br />I h.vu,trd *illnlrint,in workcri.onlrctrsolion irsurdNc. as rcquncd byScclion 37(noilhc l-uhor Codc, rbrlh.lr nrnumcol
<br />rhc work lor whi.hlhhncrmil is hsucd. Mywortc( omtcDs ion insurotrcc coricr md Flicy numhcr arc:
<br />"*",,Azl+ Fund
<br />,,... S.zb.tf
<br />-l.cnilyrhalinlhcpcrforronccolrhcworktur*hichrhi\!c
<br />nir is t\u81,Ishllltror ctrDb!xnyP.Non in rnymanrer
<br />v, x\ t, b.L{m subj.{ tu rhc sorkc6'cunrp.nsaii(,n hws or crliroiria. ,M ,8N
<br />'har
<br />il I \l'o!ld llccom shrcd ro rrr
<br />qorkc6.onlxn\di.npdvisionsofsNriotr:lr(xlofrh.Lltxrcodc.Ishall.lonhwirhcomplywirhrtosFovnion\
<br />Wr\RNINO: Fnihr ro sur *orkcr\ dnnpttr$rn .olcrrgc is unlawful. and \hall suhjcct !tr cnrnloycr ro qiminal pctulrics r d
<br />c'v,l ln,c\ up b otrc l,trndr. rhotr\rnd dolln^ lSllx).(xx)). m xdd(ueol.oarpcns0lion. ilmaper as nnrlid.d nn rh.
<br />sc.rion :10?6 0lrhc Lahtr ardc. imcr.j a d dnormy\
<br />or. S' 2t I (-
<br />-
<br />Apprtonr:
<br />Ihcrchyrfinmundcr|E.rll,olrcrjurylhllIanrliccnsc(lundspmrhiorofChrprcr9(conrncinAwirhsLtrk'n7000)olDivisnr.l
<br />.f rhc Businc$ md P^Jfcssior$ C.dc. oM nry li.c.sc t i,r tulllbrcc a cllccr
<br />o,", (,
<br />a ptlq 16
<br />29 rK AG(
<br />coNsrnucuoN.LIiNDIdG.tra[NcI
<br />Ihcrcny iflt undcr pcnrlryofpc.jurr rh rhscn!con{ruclionbndinEaactuyrorrh.P.rrunDmcolthcworklbrwhichlhisPcnniri\
<br />i{su.d (S.. .1097, Civ. C )
<br />AltlICr iLDEC!ABA.Ij0N
<br />I rrrhy nfinn u.df pcmlry oipcrjur), onu.ilhc hlloqnr8 dccl.ftlnnN:
<br />I)cnblirn,n Pcnnir\ AshNos Norifi. i F.dcrdl R.8uldtrm (Tirlc 40. Prn6)
<br />Rcqtrn.d Lc(cr.I Norilicrri,n
<br />_l ccrliiyrh.l Ihc lcdcralrcBUl ions rcgarding astEslos rcnovll rrc norlpplicftlct, rhtImrc(.
<br />r_l .d ify rhr I hr\ c rcad rh'\ snr,l'cahon mtl {rr. rhr rh. rk)vc informanon n corcr I a8c ro contly *irh all Ciry rnd Counry
<br />.otrinrcri{tr,. r'{lhrrrhtxurl(trirr rcf.c\.nhrivc\ ol rhi\ Cirr_ ifi Counry t, cnr$ utrn, rlr
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<br />BUILDING- INSPECTOR RECORD
<br />T-Bar
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