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SITE-WORK DATE ID/SIG.COMMENTS OWNER AUIDER DEL(ARATION <br />I hcrchy rllirm uDdcr pcnrlry or Fqury lhal I .D crcmPl fon rhc Conh((tri Ltcnr bw ror Ihc followins rcN)n (s1t.7011.5 <br />AusiNss r*l Pnfcsion Cdl.)r Any Ciry or Counry *hich .cquircs i Fnnn h con{d.r' 0lrn. imFmvc. d.mlirh or Ettrn anv <br />(rucrurc. prior k, ih i\quamc, also rcqutcsrhc amlicrnr rot {uch p.trnirto lilc a \i8tud ndcnEnt rhal l* or shc ii liccn{d Puruanr <br />r. rhc pnvhions ol Il'd Conrrlcroas Liccnscd tjw (Chrller 9. G,6 tncinB *ith Scclion rmo ur oivtn'n 3 of rh' Br(i'xr( rnd <br />PmL$ions Codc) or rhar lto.shc kcrcnrtr rhcrdr.'n dd rh. hn\n forthclllcPcdcxcmprion Anvviolariohorsccri'n70315l'vany <br />llpli(lntrorapcnnitsubjcc(rhc,Pplicanrlorcivill]cnrllyolnottuorhatrri\chlndrcddollds(s5uD. <br />-1. <br />us o*nc, .l rhc pmlrn!, or my cmPloyccs wirh wtC.r .s rhci {rlc (onrr.n\ar i.n. will do ItE *ok and rh. {trtm is mr <br />iDrcnhd or ofi.r.d ror sl. (58.7044- Busincs rnd ProfcssnnN Cd. Ihc Gn rftois Licen* ljw ddr nor +rlv lonnoslcr or <br />th. tmncny who hilds or nr{rovs rhcm.. st *lm dm\ \kh wo* hnnsclf.r hcrrcltor rhmuSh his or hcr own.mplov.cs. <br />pn'vidcd rhar su.h iDprovcnft m n.r irtrcnd.n or oll.rDi for elc. Ii huwcvcr. rtE huilii.g or impm*mnt is sll wilhi ok Jtd <br />.fc.nDbrn r. rhc oRrcr Buildcr *ill hrE il[ budcb ol t'ovins ltur It or ihc dil mt buikl or nryn,k rhc ImP.ny tu rlt lorFr{or <br />I. rsowtrcr o lrffi)pcny. rocrclunuclyco mclirs wilh lien{d ro rMk6 ro conddcl rhc lbjc.l (Scc 704'1. Bu\iril$ <br />d lhrli:ssbn Codc: Thecotrt&rorr Liccnsc Lr$ doc\ norttr tnr trDo$ncroltmncdy w[o huild\or i'nfnrv.s rh.rco - <br />rnJ who cont..rr li, such lrllFchwirh, C'ontrktr(n liccn\cd puAur[ k,rhc(inrrrcr{, \ l-i.cnsc hB) <br />I m.r.mrr u cr S6ri <br />w(lRKElls' c()1ll!'ENsaTloN <br />I}EIIdEAIIO! <br />I hrrchyaltndu .rNtr.ltyotpc.juryoft orrhcrulhsirgd(l!NnnN <br />-l <br />havc aJxl *illtuimatu r Ctn iararc of Coi{.r k, Scl trsurc ntr workcr'.ump(ns ion.!s pmlid.JlorbvSarion.17(t)oIrhc <br />liho! Codc. lu rh. pdlolrumc oi rhe work for sfii.h rh. l)cnni ( hsued <br />IhrvcrDdwilln(inroinsorkrs.oqxnsulioninsurancc-r\toquir.dhyS.criotrlTO0ofrhctjhorCode.forrh.l.rlonnrrccol <br />rhc work lbr whi.h rhis Frnir is Lssudl Mrworksi conrFnsrri{,n insurrtrcc c0rie.r Fri.ynu bcr arc <br />I cdnify rhd iD rhc pcrl'ormunce ofrhc work lol whi.h rhis ncnnir n i\{rd. I shrll nor cnPl(,y any |[son ir uny itrrtrcr <br />$ N rr hcc.m subjccr ro rhc w.rrc6 compcnsolion h*s ofcrlifoirrh. rnd !3B ihrr ifl ih.uld bccom hj.d rorhc <br />workcr\ coflrpcnslr ion povi\bhs ol sdion 37(t.l lhc fuhf codc. r shrll. tunhwirh .o lIy with lhos flrvi\i(n1{ <br />W^!ININ(;: FriluE ro scurc wor*cri coml'.N,ru. covcrisc is unh,ttl. ritl \hdl $rbicr sn cmlb$r o simiml Fnnhit\ ind <br />civil fin.\ up tr Dnc hundrcd lh.u$'rd d.llrs (51fi1,(xD). in rddirion n' rhc.o{ of.omPcnsrrion. drnE8cs os Prlrnl.rt irr rh' <br />Sccrioi 1076.frhr tjbor Codc. inrcc{ rnd omy s fes \-..fy..-.--ncc"-";1ffift)ffi\ 14 <br />IECIJf,AIIOX <br />I hcEby trmnnuftlcr ncmlryorpc.jurylhol I am liensi !tulo povkiotr ol Ch!fld 9 (.onmncins sirh Sc.tiun 7tr0o) olDiviri'n l <br />ol rhc Boqimss ond Pmfcssions Codc, ,rn nry liccn$ is in lull ix.! sixl cff(r. <br />l-ic.nrc Clx* <br />- <br />CANEIEIICIIANTENOING.ACDNSI <br />I hcrch, slltd undd ,rtrdxy of Erjury rhar rhcr. h,.onndcli(). knding decmv for rhe Frforfun.c oflhc wort for which rhh F,mil n <br />h{ulitscc :li)97.Civ C ) <br />t ndcr.N!m'- <br />APILTEANLDECIAMIIA! <br />I N't allnr!hd( Fnilry of Frjury orc orrh. rollowinS dNl.arinns: <br />D.mlirion Pcmirs AslEnos Notific ion tudcral Rcslh( bns (Tillc 40- PDn6) <br />-Rcquircd <br />brlcr or Norifi calion <br />Iccdrlyrh lhNc rcld rlri\rfPlrdion d{rrcrhdr1[ lrcinlaiDJi,,iscoflccr lrgrebcomnlv*irhrllCirvrtrrl(i)unrt <br />odin nccsnndsrrrctnw\rcldirSrobuilding.onid.ri(,r dndhcrchyaurh.r 7r rcfc\cnldivcs ofrhn C[y rtrd C.unry b t ci ufirt rhc <br />Jhir trf,n trtr'u,l fl,,n.ny n( 'n\pcri.n trlrlt\f\t- <br />ApDlicrnr orAEcnr Sisnortrft V \- <br />c-\ECs t[s"*ry **1-3t- tt <br />-- <br />Forms/Steel/Holdowns <br />Erection Pads <br />SLAB Floor <br />Subf loor/VenVl nsu lation <br />Roof Sheathino ,u/0<n t\N N 0't t" K't1-t a.,.1 <br />Shear Wall u( w* olLe5n lc|,fu"a <br />Framinq <br />ln su Iatio n/E ne rqy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />Ir/ aso n ry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enoineer Final Report <br />Flood Zone Certif . <br />FINAL Vt 1 (t///4t(tq ) <br />II :Certif icate ol Occupancy <br />Notes, Remarks, Etc <br />BUILDING. INSPECTOR RECORD <br />Set Backs <br />UFER Ground <br />\\tB, <br />t <br />I <br />Policy Numbcr:-Expirrs: <br />- <br />\W!e"t---- <br />-lrcnifyrlur <br />rhc ladcrr l rqulal ions rcauding nsh*nts rcnrvdl rrc or ffli.$lctolhirp(U.cr <br />I