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SITE-WOHK DATE ID/SIG.COMMENTS OWNER BUILDER I,)EI-CARATIoN
<br />I hcrc$y afiirm undcr pcnslry ol r.rjury rhor I m eicmpr amo rh. contactoB Licc.{ ljw for lhc lollo*ins ftasn (Scc 70ll5
<br />Busincs lrd Pn,rr*ion Cdc): Any Ciry or Coudy which rcquncs . P.nnil ro condfl.r. ,hd. nryorq dcnrlisn ot EPan 6v
<br />io.rxrc, Jrirr lo ils isurncc- aho,equir.s rhcapplicanr &tr suchEn.ir b fihdsiSncd slolcarnr rhdr hcorshc h liccn{d rursu,nt
<br />ro lhc pmvnions of rh, cotrlrocrols Liccnscd tas (Chaflcr 9. commcncinE wirh sc.tion ?ujo of Divi\ion I ol lh' Btrsincs 3nd
<br />Pror.srions Codc) or rhar lEorshc kdcnpr rhcmrionrMdlhc hrsk rbt rhc alLgcd cxcnrllion Any lk,larion ol Sdt n ?01I t ht rnv
<br />amli.anr for a pcrnril subjcck rhc qrtlictnt to ! civil Fnah, of nor nk th fivc hundrcd dolld3 (Ssur)
<br />-1.
<br />xs owncr orrh. prolrrly. or my cmrlqccx wnh ugcs t\ rlrt slc compcn\rrn r. will ddrhc rort ard rlt $Mrm is mr
<br />i .idcJ oi oiIcrcd for sle (S6.?tur, Bnsiftis atrd Pmlcssions clxlc l hc C.nlradols t,iccn\c llw docs nor aPPlv b,no*krof
<br />rhcpmrcny who huilds or imprcrcslhe@n. lnd sk) dds such *o* hinsellor hctrclfor rh$ugh hh or hcr o*n cnrplo)ecs.
<br />pmvidedrharsNh imln,Knrnh nrc mr inrcndcd orollc'ul for sh ll howevc( rhc hnildi'rg or inDmvcNnr is gnd qilh n onc ru
<br />ot conDklion. rhc Owncr Buiklct uill htrvc ltr hudc, of povin8 rhd h. r shc dA mt hikl or inlmvc rhc Pmtenv for rtr puqns ot
<br />gl. as osncr ol ihc pmp.ny. 0,n ciclusivcly c.nt,.ring wirh li.cnscd conlracroB b .onsrucl lhc PrcJccr lS( r(M. llusims
<br />anl Pl.fssi,n Codc: Thc Co.l.acror's Liccnsc Law does nor aPply x, oowncr oiProPcrrt uho builds or imPro!8 rhcrcon.
<br />rnd *ho .o n'ch htr nr.h nroiccrs wirh r ( onhcbrl s) Ii.c sc Coita.rof s Liccn\c l.r\
<br />IA8KIIILIjAUPINIAIION
<br />DECI.AXAII!}N
<br />I hcrchyailirE Lndrr r..,hy olPcrJuryonc of rh. rollowi g d..lanrln,ns:
<br />IhavcudvillruirrBinaCcnificalcolCotrscnlloSclllnsorcn,rw.rkcs'culPcnst,n,spovidcdforhvsccriotr-ufiiolrhc
<br />bhtr Adq for rhc l)crfoiruncc of rh. work lorwhi.hlhencnnir ir h\!.d
<br />-lhaKand*ill'nainriinworlcr'compcn\arioni.\xtaftc.rs
<br />equircdhySNrion1700ofrhcLltorG c ror lhc petlormncc.f
<br />th. sorl ror *hich $is ,$mil is issucd My workcs conrlcnerion inslENc .amr rd lrltcy numbc' dc:
<br />I .cnify rhlt in lhc pcrfortun.c ofrhc wotk lbr {ti.h rhi! r.rn,ir h rsuci- I shnll nor rmplov nnv pc6on in riy nrnnc!
<br />v, b hcmm \tr6J.rr ro rhe wolten conll'.n$rion laqs ofc0lilnrni!- and artu th{ ilI sh,uld lf,com {hjcd lo rlE
<br />korkcB cont nsrr npmvkionsofs rhr:l7mof rhcktnrCdc.I \hrll, ronhwirhonrPly wiih rh.t lmvisions
<br />WARNINC: ljailurc b sxrc workcB'.onlcnsarion colcn'ac ir unhwlil. Md \hrll $rhj.cr !n cmplo)[r io dimnEllcmhics ond
<br />civil inrs up nr u c hutrdrcd lhou\rn(ldoll ^ (51rX),([X
<br />sccrion.lr)76 ofrhc lnhr(.dc. inicrc( rnd nfrfy'\ ltcs
<br />f-t-t s
<br />IIECIASEIIO!
<br />I hcrcb, arfirnnM.r lrn0hy otrerjury rh,r I rn liensd undcr rolhion orChaPtcr 9 (comh-tuing with SNrion 7(n0) ofD*iqion I
<br />of rhc Busincssaftl PmfcsiorsCode. ard mr li.cns. is in rullforcc mdcllccr
<br />y' r"""" cr"*
<br />-"*"-^l-g-r!
<br />(IoNSTRUC'I'I(JN LFNNIN(i (iENCI
<br />I hceby riltD undcr |rrrlrrorPdrjurylh rhereh3conrlrucri{,nlcidi.Sr8ctrcytnrh.l.lanrwf,cofllr*orkr(twhi.hrhi\Iicrnriri\
<br />i\su.d (sN 1097.crv. C )
<br />l.crtirvthd rhc lci.r lr.!ulations rcxffdirslshe{o\ rcnn)ulrr. nornPplicrhlu t,rhi\ rtulttr'
<br />I.cnilyrhrr I h vc rcnd r[isrtplicrri(n,n0d ({rcr intoddbn i!.otr d l isrccn,c.nlplysirhrllCityrndCDU ty
<br />oRlnrftcsiidsrarc tjws rcllrin8 rohildi !.(
<br />rnNc trrniioncd,rn,pcny f(, iNpccrbn
<br />ofrhh City,nd Counryro.nrd uron lhc
<br />*,, Go'''
<br />Set Backs , 0r./
<br />Forms/Steel/Holdowns \nl'/.$rJY
<br />Erection Pads vl"/
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathinq {t'?AIE llcn ?^n*a,L. *t b>L
<br />Shear Wall (0-r 118 Z.z:>Pll <t-J cr,-4rt*,
<br />Framinq A . i--- lo ,,,,-..-.{r '\
<br />lnsu lation/Enerqy lu I c /o 1 ,ci4,
<br />Drywall /o//L//r *?lo>t n
<br />Ext./lnt. Lath D//;/*-67r4trn'/6)
<br />Brown Coat r{ zf,i8 ,4c.4c
<br />[/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL ./24-/B Gz 2)
<br />Certif icate of Occu anc d>1
<br />Noles Remarks, Etc.
<br />tt-a
<br />4/16 e
<br />BUILDING- INSPECTOR RECORD
<br />t,,licy Nunrbc' :-Eroncs:
<br />Lcxdq . Irmc
<br />AI?IICANTDIiIIAAA]ION
<br />Ih. hy,rnn undcr pcnrlry oi p.rjury om olrhc hllowinc leclrriio0s:
<br />D.molirn)n Pcrnrirs stEslos Noliticiion FtdcrnlRc8ulari.ns (lirlc.l0. Pin6)
<br />Rcquircd tItrcr of Miilicihn
<br />Applie,nl o.,\,tcnl Sixn lure
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