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SITE.WORK DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Formsi Steel/Holdowns r ?8 Ill u\
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framing ,1Lo|lv lGt-,/
<br />lnsu latio n/E ne roy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL ,l-291r y,Y/-w
<br />Certif icate ol Occupancy \_7
<br />Notes, Remarks, Etc
<br />OWNER AULDER DELCARATX)N
<br />I hcrchy !fifln undcr pcnolr, of rcrjnr, rhar I d ercnfl lmm thc Conra.k,F Liccn{ trw lor thc lolnrwins rcrsn {Sc.70.ll5
<br />Busines nnd Pn,tc$i{'n Gd.) Any Cny dr Counry *hich rdqut \ r trflnir ro on{fld. akcr impole. dcfrnnh o cnJn r'y
<br />(tucrf.. rrir t, ir\ nsoatuc. so rcquims rhc.ppli..d lor suchrcirnn lo iL0 sisncd slalcmnl lhrrItor\hc t liccnscd lunumr
<br />k' rhc pmvisn,ns or rhc Contaci{r'r l-i..n$d llw (Chaflu 9. Co rm.Rrn8 sirh Sccrion 7firc of Divhion.l orrh. Bu\incs\ rtrd
<br />Pmfcssio.\ Codc) or thrr tr or shc ircxcrnpt rhcrcfronand lhc h$is lorrhcalleScd crcmplion Anyliol,rt,nofSNrnnrTOll5byany
<br />trlplic0nt for a pcflni subjsls rhc lpplica ro acivilpcMllyol'nol morc dEn avc ht drcd doll,6 ($5(xr)
<br />l.r\dqncrufrhct'n)Fny,ormycmnloyccswilhwr8.sasrhcnq,bconrc'srrion.silldorh.soiktuxlrhcnflcturci\nor
<br />i'rcndcdoroll!,.dli,solc(Sa?01.|.Busin.$andProicssnnr(dc'IhcCotr.rot'sLiccnttjwdocsnor0pllykirnosndor
<br />rhc lmlEny who huildso, Nlmvcs rhoon. o.d who des flEh sij* hiDs.ll'or h.rrlfor rhmu8h hi\ or hcr oqtr crployccs.
<br />pmvidcd rhar skh irprokmnh rc nor inrcnrlctl or o arcd rbr s,lc. ll h)*tvcr. rlk huiklDg or improEnrnr i\ e,U a irhn om ycr
<br />olcomplcli.tr, lhc owNr Build.r willhavc rhc lE dcn olprovins rhtrl hc or shc Jil i.r build or intmvc thc !$|Eny f.t rhc purrxc or
<br />-1.asosrc!olthrl,({eny.!mcxcllsivclyconrracrinsliihliccn\cdc.t,.rosroconsrudlhcpmi.l(Ss.704,r.Bu\incsMd t\,hsbi Codc -l hc C.nrncr.f s Lic.nsc ljw docs n.r atplt to dn owncr of prop.ny who bt ilds or impr.vcs rhcrcon.
<br />rnd qh. conrmcrs for such pmJc.h sirh a Conr@ront liccn$d l)ur\uad b rh. conta.kr's Ltcnsc tis)
<br />c u /, /ll/t
<br />I hcr.hy xllntr, ([r Nnxlry ol|x Jr'y
<br />DLCL X llQ!
<br />IhJ\ctrnd$'Llmrinr n,Cc ifilru rc,,n\.nrl,SclrlnsrrcntrwoAcsconrp.nsariotr.asprovidcdlbrbySccrh'17{x).lrh.
<br />bl^.' .oi[. lh' rh. F hnmITc,,l rhf s'L u' \M h,h. ndnnr !s cJ/
<br />-l
<br />havc ond w ill Nri hi. sorkcr' compcnuri.n insurrnce, !s rc+itod hy scd iol lT0O oi rhc tjhor Cod., ,or rhc Fnnnuncc of
<br />rhc wo,k forwhichrhi\ pcmir is nskd Myworkcn .onFn\rrion nNtrrdn(. cMict nnd Bric! Nn$d arc
<br />PJ tr ) \unrh1
<br />-l
<br />ccniiylhol inltc pcr{ornDrucotrlE sor\ t" *hi.hrhi\ Frnir i\ issx.il,I sh,ll nor cnrloy.nyr.tron in anymrnmr
<br />$ N b h$m \rbFcr ro r hc uolkdc con{cnsarion Lvs ol calirdni0. .nd a8rcc rhlr if I should t6oE subjcd tu rtr
<br />Rorkc^ co'nl.Ndion pn,vi\bn1ofScction l?00ofrhc btlr GrJc.I shrll. fonhlirhcomply wirh rho{ nn,vi\nrn1
<br />WAINING Foihtrc lo slrc workerl co.rrensalion covcmsc h unltrwful. nnd sh3ll subjdr nn cnll]lo]tr l. diminll pcNllics rnd
<br />civil fincl up l(,.n. hundrcd lnousand dollds ($l0O r. u r(l,liri,nr t) rh .o! o, .o' tcr\ari,r. drn[t.\ r\ frirkl.,l htr th.
<br />sNh"n n16 q{ rMih., c"dy' inrcrc$ and,,,",7/tQ/u
<br />^
<br />€
<br />I hcrcbr_ alllrn unJc. |{.nlry ol tcrluryrh.t I 'vhion
<br />of Chnprcr 9 (conxmncing *irh sftriotr ?mo) ol Dilhion ll
<br />of thc Busin.sand Polissbns Cod.. nM nyliccn{ ir ir full lorcc andcliccr
<br />!:A!$BI]IIIQNIIjIDING.AGINJ:I
<br />I hcrcby rnlrDUndcr lin,liy ol l.rjury rhd rhdc h a..nntudi,,n lcidtrrs rpcn.y lor rhc pcrhrnuncc olihc $ork tn *hich lhn rrmir is
<br />nsucd (Scc.l(D?. Civ C.)
<br />APILICANLIIEIIA&I.IIgN
<br />I hcrct'y ilti.nr u lrdc r ncnalry.ipcrjury onc oilhc foln,wins dcchrrrn,n\:
<br />Dcmlirbn PcirnirsAsb.sos Norilic[ion ljcdcr.l RcSuhrins (1 irlc 40, l'rda,r
<br />Rcqutud Lcrf of Noril.nrirn
<br />IRFE
<br />BUILDING. INSPECTOR RECORD
<br />Erection Pads
<br />Flood Zone Certif .
<br />Irndcr'. Addrcs\
<br />-
<br />I ccdity rhxr ihc fcdcEl r.en lar io ns agardinS rsb.sros rcmvrldrc nor ortliclblc lo rhi\ pmjccr.
<br />-l
<br />(cniryrharl lfc rcrd rhhannlic rn and dsrdhnr rhc ak,vc inr(rturion ir cor.ct l ngm lo.omtly {irh rll Cirr and Counry
<br />qdmq.fs and S'rc LI*\ rclahns h hrrldins .nn(h.non. a l h.rchy JurhoM rcprcsnrdrtr es or rhr Cr ) and Cou,rly k' enrc' df.f, rh.abor\yr/rmeciy,o,in.,t"K 2,4 6,/g
<br />AppliNr orhr.{sismrury-- ! : , Dste.'
<br />*-*"t",,n;/ K-<-"-'r tnV
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