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BUILDING- INSPECTOR RECORD SITE.WORK DATE ID/SIG.'COM,I/IENTS Set Backs Forms/Steel/Holdowns Erection Pads UFER Ground SLAB Floor Subf loorA/enVlnsulation Roof Sheathin s Shear Wall Framing lnsulation/Energy Drywall Ext./lnt. Lath Brown Coat Masonry Pool Fence T-Bar Handicap Req Qgputy Final Report E ngineer Final Report Flood Zone Certif A AFINAL?/zo/r0 .,/"v Notes , Remarks, Etc 7 OWNER BU!LDER DE!('ARATION I h6q.rm u..lq Fnalr, or pajury thd I m.rmPl nrm $. Conm.rou' lr.n* Llw tor rh. followin8 iasn (5(.7031.5 Buin6 rn Ptof6lion Co&) Ary Cny or CN! y Bhah t.qui6 . rEni lo connrud. sns. ihprov.. &rclirh or GFit 6t o\.t@, Fn. 'o !r. i!se.,.k rcquic tlr +plt n for kh Fnir ro 6l. ! ris..d ctal6 lhrltordEi!lkos.d FEd lo rk ForirioE orlh Conlr.ctd! Li.cnr.{ Lw (CIEF. 9. Coffius wnh Sdrion 7(100 of t)lvilbn I of rh. A6a.d ed Prcf.si..! cod.) or rhar lE or rh. i. qnfl lh6.Iior !d fic tsis lor rh. .ll.s.d qdFio. any riol.lion of V!1i.n ?011.5 b, !n, .pplicel for ! Fmn lbjclr lh. .prlicul to . civil p.Elty o f mt mrc tns fivâ‚¬ hun&.d dolbs (1500) _1. a ow oldE FoFir, d Ey.npbr6 *ih srg6 6 fi.ir $h onFdion. rilldo tlE f,at rd tlE didE a d iirq'd.d o.offsld lor slc (Sa ?0t21. Buir6 Ed Prot6ioE Cod.: T1'. ( odr.dr't l{de t r'4â‚¬ml tppl,teoffol lh. rn,Fly wno hril.h o. ioF!6llEaq .Dd who &â‚¬ rEt wlt fiir*lf or h@lt or rhrouah hn or hd om.mploy6. provirLd thi r.h imFltEfu e mr ii.rddl dolH 6. sL. Il how. tlE hlities or rry$-oEr i! $ld vthn m,* ofNnplrno.lrE (xc &ilb wil lhr E hdc! ofFrng dr tEd JE dil d blild d in$.sr 'lE FoFiy for E Flpo-of L a ow of rh. FoFty, m dclNnrly conrdine wirh licas.d co.rr.doB io oBlrucr ttr F!j6r (SE. ?04!. tl6De d ho6si CoJ. Ih.C6 n.tor't Lic6* L* dos 't et,ly lo d o*nd oaFoFry sho bu,LL o. ingN6 rh.on. ud tr lE olndr an sh Foj.(! *ilh . Con*.(t l.au.d pl6@ ro rlE Conhdr'r lilg L.$). I etrâ‚¬râ‚¬mpr 0nd6 Sdnrr .lr. & l'a I h6.tyltnmund6 pc..hy.tnâ‚¬iuryon.otrh. tollosiru ddl dio -l hlrc rn sill di !i. . Cdifrd. of coMt lo S.lf-lBur. for wl6 @mp.nt 'oq a proriLd for br S6lb. 11700 orltt t hr Codc fd rh. Ff M.ofrh.surtur'tihrh Fmn bi$.d _l h.r.od wiu dlinGio ,o*.n' cofrF. ion iBu!nc., 6 rcqutcd hy Sdnon 17tu 6l rh. kbor (ild., aor rh. FfomMc. of rh. srl fo. *hi.h rht Fon ir i{u.d. My wo 6i .omFGlrio. icur4..nir atul p.licy.rnbd ft Policy N@ba:_Erpn6l I Giiry th, ir lh. Ffolrmc of th. rorl ao. *lich 'ht D6hh is i]lal I snlll nn opb) ur Fe. id oy nl.ljE $ arohe6tr.utdioth."rrt6 6rDFEii,. l,*r otcd'aomii a +rfiiif I$o!ldh<oE$b..llollE uorl6' conpsu ion provnioB of Scrion 1700 otrh. t u)r Codâ‚¬. I ddl. fonhwirh omply *ilh rhoF ptuvisioB wARNlNc: Fole lo su. mrta @npoBllion ovdasc is u.l.sful, ed slull .ubl..l s aploF to aini l FEhir dd .ivil 6nd up ro oe hu.dEd tl'oN.d dollr! (ll()O-001)) scrion 1076 ofrlE tlbor Codc dt6.n ..d .ndr.y-3 f6 I hdrb, .rm uid6 Fuly of Fjury tL l 6 lico!.d u,'ds FDyiroi of cl!4l6 9 (o,rlj4irB whh setb. ?m)) of Dniin I of rh. t ciIB !d PrcfdhE Co&. ad mr ltoe ir in lull forc. rn .lIB! cQlilBululla.L[dull;lcEx(} I @ lrm un&r Fuly ol Frw, lht rlEc ir . ol(ru.1bn ladlts .sdy for rlr FfolrrrlE of 0r s.l for {trh thi! Fri ii i!.u.d (sd 1097. civ. c.) A PPL'C ANT DFCLA R^ ION I ho*y alfim un& p.n.Xy of Fjury oE ol tlE lolbwi,g d..LrdioN: Doelnio. Pmne^ib<nor Ndrtr{ion F.ds.l R.sullrnd {Ti1..rc, Prd6) R.quir.d t t!6 ba l'+orifi.dh. - I rdr ry rhd rh. f.ddd rcsuLr oc l!8edinB atGros rmrrd d. nor la,r,lrcabL to rh6 Foj.ll -l cdiry rhd I hAc iad rhn rlrlE.iion ai rn.rhd rh..b\. infotur)n 6 I r8ra ro onpt $nh .ll C } od Courry rlrv6 ofrhG City Dd Co@ryro ord lpoo r&odimM6 snd S'dtl t,ss Ehl iI{ ro bu'lding ah,v. rhdrion.d l(rmr r'or iNFlhn .tppli..nr or.\8dr Slan.luF ,"-u*-..,0r^,' Ri o. ^,. /o-bl-ag b..r -T------