|
SITE-WORK DATE IDiSIG.,, COMMENTS OWNSR BUILDIiR DELCARATION
<br />I hcrchy rlfifln uMc! |xtr0lly ol i'crjury lhol I am cxcnpt tmnr lhc Conlrucxn\' l,ic$* us tur lh. rolhNirB rurs. (Scc 70ll 5
<br />Ilusincs and Prolt$ion Code): ny Cily or Couory whth rcquncs a Frnir b ondfld. ,lrs. inI,ovc. dcmlin, or EPan u,
<br />rfl.rurc, rdtrr, ir\ issuftc. d$ rcquircs rhcrppli.nd lor srch !.n r Io flc! sia.cd (ale.rnr rh{rhcorsh. n li.ciscd pur\u.nr
<br />nr rhc pmvisnns ol rhc Co rlcloi\ l-iccn{d l,* (Chrpr$ 9. Co xncm'ng qirh s..riotr 7uD of Divtion .l ot rhr Bu\ioes and
<br />l\ofcs\i.trsCodc) orrl[ h..rshc iscxcmfl rlrr.fion M rlr hr{s hrrhc llcacd crcnlorion Anyliolarion.lSe.ridT0ll5byrny
<br />irnli.anr fo.r,,cflni suhjds rhc applic.nr ro acivilpcnrllyofnol n{rcrhrn 6v. hon&cd doll \(35(n)
<br />l. as owfti .r rh. p$trdy. or my cmployss qilh wrBc\ .s rh.t s,lc conwnsll ion. will do lfu $ork and rh. {d'm t m'
<br />i cndcd or olitrcd lir eL ( SN ?oi4, Busincss und Pmfcssiotr! Coic 'l hc Conractri I -nu\c L:w docs nor !p!ly l{, {n owmt of
<br />rhcrn,ncny who hoilds.r illq)mtBrh.B . ml who des ach trn,i hirscll or h.r*lf or rhtuu8h hir or h$ o*tr c,nployccs.
<br />pn,vidql rhlr such inlnrkmnk m rt ini. lcil oror. lf(rkL ll lbscvcr.Ih. huildiry or in{)DE E.r G $tl sirhin.nc yr
<br />orcotrDLlirn, rh. owtr$ Buildcr pillharc thc buxtctr ol pmvi.g ltul hc or shc dil nol huild or imphve thc p$ldy for rhe Puqnscoi
<br />Ls.wn.iofthcrior.ny.arcrclusivclyc. ractin8 wilh li.ened co rrckn r h c.tr{flcr rh. pft'F.r (S.c. 7(}1-1. Bunm$
<br />Md Pn,issi,n Codc l hc Conrndoi s Lic.nsc l-sw do.s .oi rnpl! i. in owN! of pro!.ny *h. hu ild\ o! imprcv€r rhcrotr,
<br />rtrd who ontrocrs for such prorcch wirh!C.nlndo(s) li.cnscd ruGo"nr rorhc Contrcrofr Li..nscLrw).
<br />-l
<br />amcicorl undcr Scclion-. A. & P.C. lor rhh rclson
<br />Dole: Orner:
<br />WOR(l1RS,('I)MP!\SA'IIoN
<br />IICLABAIIO
<br />I hcrchy rffi nn uulcr lrcnrlly of pcrjrry oN orrhc r{'lk'*ing dccln.!ri{trs:
<br />-l
<br />hovcud will Ninrlin a Cenlfic colConscnrroScl|lnsurefor$n.kcis.onFns.rn,n,N p.ovid.dlorhlSccti(D3?{xrorlhc
<br />l-lb.r Codc. lnr thc rc brronce ol thc work tbr which lhc pc.nrn is hsucd.
<br />lhrrca wiu ntinrain sorkcri conT.nsrri, in\urrncc. r\ Equncd hySccrtrtrr:r7(Xlofrhc L$orCodc.16rlhc pcrlinroktol
<br />rh. work fttr *hichrhis pcmir i( is\ucd Nlysorlr^'o lPcnsrrn'n i'sunncc cari.r md policy Nmhcr e:
<br />I.cnifyrh i.rltr p.rloirnrkrolthc $ork ntr $[i.hlhh pcml i{ n\ued- I lhEll nor cnlpl,,y rrytcrsotr irr trtrynratrrcr
<br />v, A kr tr.oN shF.-r h rhc k,rlqs dnnFn\rrn,n uws.rcrlirdnir, an<l4rcc rh.r if I shoukl tf,com suhjccr b rh.
<br />woikc.onpdnsri{DprovhionsofS..riof]?mofrhcbhitrC.{..lsh0ll.lonhqirhcomplr$irhthoscpovtions
<br />WARNINC: Iirilurc ro sulc workcn'comlcnsorion oEnsc is utrhwful. lnd \hrll srbjc.r m chpbrcr b aininrlFmhns ond
<br />civil fircs un lo oN nundrcd lhousrnd lolla^ (S100.0tx)). ir add or.omp.ns,rion. d,mBcs os protidcd for rhe
<br />rhc ljha.(ode. inr.r.{ md arkrncy s tc.\tqLO{ Appliunl,\ l_,!
<br />I h-rcby lr und.r F.,lry oa lrrjury lhnl l ,m licrn\.J uMf Eovision oi Chaprcr 9 (commncins wirh Sftri(, 7(xx)) of Divhion l
<br />or lhc Bu\incss hn PDft*tuns Codc, dd my liccn{ is in tull r .c , cffccr
<br />v, clo \z^rz-VGqF4lLg
<br />I herchy aittnr utrdcr lrnllryoirerjlry thll Iherc n a conslrudir tndins lEctu! llt rhc n rft,@n.. orrh. $ok for shich lht IEnni n
<br />ksucd (S.. 11097, Civ. C.)
<br />APII.ICANLDECIABAIION
<br />I h6{,! afilnn undcr pctrih} of pcrjury onc oflh. fol,osin8 d.chmri.n{:
<br />O.n,hion P.rnnrAsb.sos Nolifi.arion FL'dcrnl RcSuhridns (Tnb 40. P!n6)
<br />Rcquidd Lctrf of Norifi cdiotr
<br />-l
<br />ccnilyrhlr thc lcdcra I rcsu lar ions rcgdins *hcsros rcn$!!l nrr ..r rpplic.hlc Io rlris !mrc.t.
<br />I c.nifyrhrr Ihalc rc rhn 'mli..rdrnM s rc rhd rh. fi)v. iiturnNn Fcotrccr I r8relocomnlywirhxllCiryrtrd Cuunry
<br />odinnkrs utrd srarc llqs rlming b huildi'rg.otr{ncln,n, dd hcrcby flhFDcrclncscnldilcsolrhhCit,undCoun'yt,.nrcru!.nrhtr
<br />(^g
<br />a
<br />I >4 (
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Sublloor/Vent/l nsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framing
<br />lnsulation/Enerqy
<br />Drywall I lefl /norrAr r,O-"/
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It/ason ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL t(u4qfa
<br />Certiticate of Occupancy r-l
<br />Notes, Remarks, Etc
<br />BUILDING. INSPECTOR RECORD
<br />Set Backs
<br />UFER Ground
<br />t nJfl\ AJdrc!(
<br />-
|