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SITE-WORK ID/SIG.COMMENTS OWNER BUII-DER DELCARATION
<br />I hcrchy 0itnr undcr pcmlry oI,Erju.y lhd t dr cxcmpr fro'n lhc C{nnrncbd' I-i.dn* bw lot lhc lbllowirs rmsn (Scc 7)ll 5
<br />Busincss itrd Profesion Codc): Any Cily or Counr, which rcqoirc{ d Fnnir h otrnru.i. .lrcr. nnprovc. dcm,li\h or Epd my'
<br />srrucrurc. p orro irs hsun.c. fio rcquirct th. rptli.n r for skh Fmnl to filc! siSncd slal€rmnr rhar hco. shc is li..nsdd ,unuMr
<br />ro rhc 0o!hio.s ollhc Contactois Li.cned Ljq lctlplcr 9. ComntnciiS wirh s.crn ?(x olDivnionIolrhc Busincs aid
<br />Poic$ions Codr)or rhd lr or\hd kcr.nDr rh.rcfr.naid rhchrsis turrlt 0llc8cd cxcnrtrion AnrviohrnrnofSc.lionT0.ll5by0.)
<br />rmlicatrr ln Frnrir subjccBthc rfllicanr lo acivilpcn0lryolnor m,crhln fiv. hu.drcddoll s($5m)
<br />l.a
<br />-1.
<br />as owncrolrhc !.ollcny. or my.nrLrr.s wirh *.8.1* rhcn $h ()nlpc.s.lion. willdo rtE wort sJxl rh. {nEtm t Dor
<br />inrcndcd orollLrcd for slc {S.r 70{4- Buiinc\r0 PmLr\ions Cdic: -rhc GJnrad.rs Liccn{ l-awJo$nor aprlyroMouncrol
<br />rhcF)p.ny who builds or iryrovcs rhcNn. ud sho dms skh so* himi.lfor hcrslfor rhmugh hh or hcr owtr.tr1lloyccs-
<br />providcd rhar \uch ir{,rovcmin m nor imc*lcd or orfcrd for slc li howcrcr. rtE buillillg .i i'nl,l.\tmd t sk wihin oE ]ttr
<br />or.onDlcrk)tr. rhc oqrc. Build.! *illh.rc Ihc bur&n of F,vir-q rh{rhcor dr dil mr build or i pfl)rc dc rmltrly tur rlE r{qiN ot
<br />-l.
<br />rsosncr.irhc prcpcny. anrcr.lu\ilclyco ts.r inA *irl li..n\cd .ofiu.kr\ ro con(tucr rhc In*d (Sc. 7(l1'l. Bunrc$
<br />n'kl ti,fc\si,n Codc: Thc Conrllcrols Li.ctrsc Laq d.cs nor lpply kr rn o$nci olpt)pcny aho truilds oi nnPrcvcs rhcrcon.
<br />rf(l *h. .ontrf,.r\tur\u.h pnitc.r\ sirh l d.knlno li..n\8t pur\uatrr t)rh.Crtrkr.ktr s Li.cn\c us)
<br />L,t \
<br />D[!Lrl&Ill!)!
<br />I hcrcby alltm undcr pcMlryolpcrju'yonc.rrhc rol
<br />-l
<br />hrk irxl sill nhn i'rrCcirill.rbolConscnrkJScllltrnrchrsorkc-co'npcr\riiof.x\pn,idcdfrrhySccri({.17(x).1rlrc
<br />l,ntxtr Codc.li)r lhc |E ioi,uncc ol rl[ sork lnr qlrich rhc lrnnir is i\{rcd
<br />l ha\rand sill ri ainworkcrsconUrnsolioninnroncc.arrcqut.dbrSn.'rtrnlTtD.frhcLa!{trCodc.lorrhcFrronnanc.of
<br />rhc *orr lor *hkh rhis,iqnir is issuLn. My *orkcr' dnnpen\arion nNursn.c.rnid toi !.licy nunrber ue:
<br />lcrdily rhrr ir rh. Nnainrn.c olthc sork rd shicn lhn rcmil is issud. I nrll ior .n[loy any pcNon in an] manrcr
<br />w ns lo bc$nr suhjcct k'lhc *ortc6 conwtrsrrion l!u\ or Crlif(flir. and r8erhd iIl \houklliconE slh]c.r rorlt
<br />wo cn conuEnvtionpovnionsotSaliotr1700orlhctlhrCodc.lshxll.lodhPirhconrPlywirhlhoctmvkion\
<br />IVARNIN(| Irdlu'c n, \..urc qorkcrs coml[trsrru .olcruc L( unhslul. ]tr.| \hrll \ubicd trn .i1doy.t h drin Fnrhi.s rn'l
<br />.ivil l,nc\ uf ro onc hurdrcd thousoDd dollm (S lddiriitr ro rhc .o{ ol ronrrr \ n{ dimnxc\ r\ pn)vid..t nn r[c,:::HWf-,:SqXr,r, *
<br />I h.nby Jfifln uid.r Fnnh, ol Frjury lh limliccnsctu ntrri,tr,ol { h,'I.rqr.onnNi.i r! \'irls.(ri,,,?(x{)i,)l lr rN(nr I
<br />ol th. Bu\i',c\sxnd Pnilr$rtri\Crd.. rtrd n[ ]r.nr Ll ir I',ll
<br />TNIIII]CUONIINDINC.&AIN1;I
<br />lhdtuhy rfitdu l$ Fnrlrydt lErjuy rhlt rhcrc n rcon{nrcrion lcndinsasc..y r.r rhcp.rfitr.urn.c ol th. \'ork a(tr$hi.h rhi\ Fnn[ n
<br />n\!cd (s.c .lll97, Ci! C.).
<br />Lcnd.rs NraE:
<br />-AIILICANLDECI.AAATA!
<br />lllnhyrllinu .rpttrrlryoltrrruryorcolrhcl.lloainSd&.llrrlinr\
<br />Dcnmlilidr P.nnirs Asnrslos Nori6.rri,,n FudcrrlRcgtrhrn \ llnh 40. Prrr6)
<br />-Rcquncd
<br />tJttcr of Norifralio.
<br />I ccnily rhd lhc lcdcral rcBull ions Essdins lsb.sros rcmval ft nor ,pplic$k b thn pojccr
<br />I ccdiry rhar I haw rcdd rhis aprlic,lion o,n slutc that lhc abovc infornurio. is.omr.I trgm roomPly*itn aU Cirydnd County
<br />. i' n.c\ xnd Sr3rc l-rtr\ rrl.[ir8ni .rninr.ri( . dd hcrehy horiTdrrt)r.\.nr[nc\oirhi\( 1r_rf,l(ir ]_t,.n1c'u|xmrlf,
<br />rhrvc nrnlidrcd rqEny i)
<br />\pplnrDr !tr \[0] sixtr r ,t o,
<br />t/-( ot.o\
<br />2/z:/tt:
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq
<br />ln s u lation/E neroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil
<br />FINAL ll)a lLa r<irl,<1to*11 ry,/
<br />Certilicate of Occupancy T u_l
<br />Notes, Remarks, Etc
<br />BUILDING. INSPECTOR RECORD
<br />DATE
<br />Pool Fence
<br />I L.r tr. ( li* l-(. .. N, r'ri1
<br />l)ilr
<br />=
<br />I
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