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SITE-WORK DATE ID/SIG.COMMENTS OWNER AUILDER DELCARATION
<br />I hcEhy nlftm unds t'ctr{lly ol Dcrjury rhar I rm.rcnpr fftnn rhc Contruc(B l-i.cnsc l-trN for rhc follo*ing rcannr (Scc?0115
<br />Bxli'lcs rd Prorcsion Cqte) Any Ciry o! Counry which rcautcs . tlnlil t. .onnrucr, a,ts. inprovc. &nnlnh or Epln rny
<br />nrudurc. Plnlh irs *surn.c,0ho rcqu,rcs rh. lppltnnr f{r slch Fnnir ro lilc a riSncd nalcmor rh hco! shc n licc!\cd pususnt
<br />lo rhc p.ovisions.rth. conracd s Li.dh*d ll, (Cluplcr 9, Connncn.i.rs wilh Scclnnr ?0r0 ol Divnnrn I ofthc Businc$ rtrd
<br />Proacsst'nsCodc)orlhnllrcorshchcxcmplrhcrcft.m ndrhc hlis turrlr rllcscd cxcnrtrion AtryvidarioiofScibnTO.ll5btxny
<br />rpplicrnr ntr a pc.nril subjccrs rhc ap!licrnr Io o civil !cn.llyorDor nrrc th,n fivc htrndrcd doll s ($500)
<br />L ns owhcr.lrh.ItuI,jny. oi my.hpkrycrs wilh s ses !s thct solc conrp.nsllion. silld.ltE work ffd thc \trururc n nol
<br />inrcndcd or ofcrcd lor ulc (SL!.7t)1-1, Busirc$ rn{l Piofcssn,ns Cdlc Thc G)ntrt,\ l-iccnr uw do.s nor apply b 3no*Nr oi
<br />rh.F,pcny wh' builds or inUoE\ rh.E$n. orx! who dN\ ruch sod( h,nNclfor hcr!.lror rhnrulh his or hr o*tr cmpl.tces.
<br />t]n)v'dcdrhdtsu.h i'nptvc $i*,r. dor i cndcil oror]trql lbr \nlc lr: k)scrr. rh. ht tlir or irn NuEnr i\ sld wilhii, c)rJt
<br />olcompleli,,n.lhc osncr lJuiHcr *illhalc rhc hofllctr.itn'rnB rhr' h. or \hc did tror htrikl or i'npmw rh. lmFry ror rlE rurthr or
<br />l. r\ustr.rofrhcIroF-ny. amcr.lu\iv.lyconrrcri'rg *nh liccnscd conrrrckn\ kr con$rucr rh.IrcFr (Scc ?0i14. gusm$
<br />r thncs{iotr Corlc l hc Conlr&ktr's Lrcns. Lrw dods ndr rtply n) nn owNr or l)ft,pcdy who hrilds .r imlrovN rhcicon,
<br />rnd sho dnnrr.r\ tur \!ch ptr,j.cr\ sirh r Cotrrmcr{n(\) li.cnscd,rtrNua hrhcConrracroisLiccn{ctjw).
<br />l,n'.r.n,l)rldcr Sdcrnnr_. B. & P.C.lbrrhis rci{nr
<br />Drle: Ovner
<br />lVOR(ERy C(|luPFN.SATTCN
<br />aEllA84ull
<br />I hcrcby rliinn undcr t^..n,lry oi trljury onc orrhc rolk,wiis dcclar n,i\:
<br />Ihdvcn' s ill trx,i'nrin ! Ccn ilicarc or Con{ni n, Sclll trff. ior *orkc^ $mNnsrrioo. r\ pnviJcd fitr hy Scuriotr .l?(U of rlr
<br />ffi";
<br />Itr lhc lE 'oirruncc ol lhc work l'or whi.h rh. pcnnh i! i\\ucd
<br />sh'.h(h,s tu ir ,\ LUCJ Mt co'nr.nsrrion iNuEncc .rdcr dxl rolicy nu Dhcr rc:
<br />:o t(or", ".,*, U1,/ L0 i
<br />l.cnifyrh.t inrhr If,rfo.nriccofrhcwork ntrwhich rhi\ pcrnrir i\ isrudd.I\hnllior dirPlot any p.^on inant mncr
<br />$ rsrobtcorx sut'jsr lolhc sorkcF c.mpens0lion lowsolCtrlifonrin. ind ryrcclhot i,l sh.uld tEconrc subtcd rorhc
<br />*orr.n compcns!ionpmvtions otsccrn.:l7lx)olrhc L'try Gdc.l \h!ll. forrhlirh comrly wilhrtos lrovisions
<br />WARNIN(;: t,Ilurc to scurc solkcr coDpcns iotr corc&Ac is utrhwtul. nM shlll sublccr otr cnrtlo)cr ro sm n0llcn0ltas ind
<br />civil 6ncs up ro onc hundrcd thausnd ilollm ($l0l).tro0). in rddilidr ro rh. con ol co.rtcns.rnnr. d{ru8cs.r prnridcn io!
<br />'hc
<br />;::ryliryi$
<br />I hccby.mrfl ud$ p.Mlly of pcrjuy th,r I an L.cnwl xndcr pblnii)n orchlprd 9 t.onmn.ing wilh Soliln 7tD0] ol Division l
<br />or rhc Busirc$und Pmacssi.n\ Gdc.!ftjmr liccnE h in lulllorcc uftl elitcr.
<br />v,I c
<br />tr)2El I I
<br />!!)l-lt!](l.rlN-Lr!!!tl1ji!
<br />I hctoby nllnh undrr rculirofFrjtry rhr rhcrc is r cotr{ru.riotr lcnJing rgcnct for rhc pcrrornuncc orrhc work lor which rhi! Fnnn ir
<br />R{rc.lrs.c :1017 ('iv C)
<br />l,cndcrs Addrc$
<br />AITLrIANLDECIABTI]ON
<br />I rrrby allinn tr n,l.r pcmlry ol ll{rjuryoN ottu hllowif8 ncchrrrion\:
<br />Dcnnhion ttrmih'Ash(nos Notification ltderalRcEulirions ( rirk 40. Prn6)
<br />-Rcquircn
<br />br'crol Noriicarbn
<br />il,rnilj rl- rt. fc,lc'Jl rEulJri,n. rpJdilp B.h.r{,.nnrJlJrc n,{ 'mli.:l"lc rn rFn pmr.r
<br />fh,#+n,,n.,,*'.*u,'n^JnnlE.ntrinlndqnrcrhrirItribroinLnndiotrN.oncdIasrero.ompl,wirhallciryrndcounryordr{rlc.rnd Sr,t Li*. Rl,inE rnburld[s (otr{dcrn,n. dt hcrubylurh.rizcrcprcscnl ilcsoflhisCnr.ndCounlylocnlqul)onrtr
<br />rir,r. n.fl r, r t'r'trdt ntr
<br />\(qtr\x ^'.,X|L5LY
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenUlnsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />framing
<br />lnsulation/Energy
<br />Drywall
<br />lVlason rY
<br />Pool Fence
<br />T-Bar
<br />Handi cap Beq
<br />De puty Final Report
<br />Engineer Final Report
<br />FINAL U\1,t\\9
<br />^rxrl(\)\Certilicate of Occu pancy
<br />Notes, Remarks, Etc
<br />BUILDING. INSPECTOR RECORD
<br />Forms/Sleel/Holdowns
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Flood Zone Cefiif .
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