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SITE-WORK DATE rD/srq COMMENTS
<br />Set Backs r-ls4v r,VJlt
<br />Forms/Steel/Holdowns v-t94K v,lffiL
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation ,A
<br />Roof Sheathing q-t1--/K
<br />Shear Wall 1"t7 -/k'
<br />.i-e)Framinq p'-ts:-g
<br />lnsulation/Energy JEf rale 1 Z7J^^ I vl --^
<br />Drywall lr1r"1 ,0 '-/2
<br />Ext./lnt. Lath I
<br />Brown Coat tt[1lLY I 'D-)
<br />lVlasonry l u!
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Cefiif .
<br />I
<br />FINAL rzlott-n "4,/
<br />Certilicate of Occupancy I
<br />t.
<br />I)
<br />Notes, Remarks, Etc\r y',/a
<br />r,-l!/atl(./
<br />-+
<br />OWNER BUILDER DELCARATION
<br />I hcrehy iffi,nr undcr pcn r, {,r pcijury rhd I m crc,nfl frcm thc Contrrcxm Lic.n{ trw aor rhc followin! rca\on (sft1031.5
<br />Brsiic$ dd Prorc$ion Codc)r Any Cily or Coutrry which rc+nc\ a ,riinir lo consrrucr. ullcr, improvc. dcndnh or rcNn uny
<br />rhctu6,Itrioit its issulncc. aho Equncs rht,ptlicanr ro.\u.h tfnnil lo filc a sisdd { cmm rhtt h. or shc is licenscd pu u,ir
<br />ro rhe rolnioN .r rrE Conrm.iols Liccnscd L.w lchaprcr 9. Comtuncing wirh Scdion 7fix) oi Dilhi.n ] ot rhc Busin.s ond
<br />Pnrrcsn,n\ codc) or rhil hc or sh. h cxcmpl rh..cfron ard rhc basil lor rhc allcScd excnrPrion Anyviol,rionoiScclionT0ll5byany
<br />.pllicrfl ior . pcrnrir subjcck rhc amli.d.r ro a.ivilpcnlllrolnot nmrcrhln fivc hundto'd dollarc (S5(U).
<br />I l,a'
<br />[tLr, * ,,*n* "r rr." rct"ny. nr rny c'npl,,]s' N h wdgcs ns lh.ir slc conr!.nsarion. will dD rh. work d lh€slodmi\not
<br />inrcnlcn or olt'crcd for eh (Sd.7o44. Busincss and Pmlcsions Cods Th. Coih.rofs Liccnsc Lsq docs nor rPply ro !n owrc! ol
<br />rh. ln,lBn, shr huilds or nnr,m6 Ertr rd who &f,s {ch *otk hinsclf or hcrrll or rhr.ugh hh or hn o{n erq,loyccs.
<br />providcd rhar such impowmnh c rbr inrdrlcd or ollcrcd hr sh lt t6*c\tr, rh. buillinB ot tn{'mwnrnr k q,H sirhin onc rr
<br />or.omphlirn. rh. Owncr BuilLr will hlvu Lh. burdcn of rtuvnB rhll hc or shc dil nor ttuild or impDw fic prefany for rhc purlDc of
<br />)
<br />I
<br />l.rso{rcrofthcImpcny,anexclusivcly..trt{ctrDgwirhliccnscdconrrncknsr...trifl.llhclDjcci(Sc.7(x4.Busncs
<br />rnd Ptr,lissiiC.dc lhc CoitBcl.ls l,icclsc l-ae docs nor appllroanownctofProFnywho huildso! inrl,rovcs rh.rcon.
<br />trtrd $ho conrndi lnr ru.h pruiicis wirh r Conhcrons) liccnscd lunuanr ro rhc Contradol \ Liccne hs )
<br />-l
<br />umcxcn{l lndcr Sccrt,
<br />^,$74.f Jgs1X"''',".K [2t
<br />DECUAd.IION
<br />I hcrchy r0nin u.dcr Dctrllry of pcrjury onc dfrhc ldUowinE d(lrroliofls:
<br />Ihv.rDdwillnminlrirsCcniftrrcorconscnrrosclf-ln\urcrorworlcrl.onDcisdtrrr.rsPmvidcdrbrbys..rion]TUJollhc
<br />Lrhtr Codc. rorrhc p.riornrrcc otthc wo n, *nich rhc Fnnii is isucd
<br />t hav. and will mainrrin u'orkcrs coq).nsarion nrurrmc, rt rcquir.d hySdrri.n l7(xJofrhc Ubor Codc. fdrhc rcrfoirlEne ot
<br />rhc rorklbrwhich rhis p..nir i3 is\81. M, wortcK comtcosori.n insuDncc.lricr a, Flicynu'nl,cr m:
<br />Policy Numbcr
<br />-ExPn
<br />s
<br />-
<br />y{, *^t, *" nthrI,. n,mnlcnlrhctrorlr,tr{h'.hrhi\pcrtrnaisnrcd.I\hallnor.,!lt,yrnylcmoninadvm mr
<br />$L!L,h\.trrsuhlccr!.rhc*o'r.'i,,'nrcur'.trlrw.ur('rlrion.tr'l'srrrhr'fI\lFultlhccinf,uhjNlL'rlF
<br />rukcrs, conrpcnsrlion pmvisn,ns.fSc.rion l?0Oofth.ljh1r Codc.l shnll. fonhwirhcomply wilh lho{ pmvNnrns
<br />wARNlN(;: Frilur. n) wurc Nnrkcr{ conrpcnsarion covcragc i\ unl,vful. rn \hru \ulr.cr M cnrllo}cr ro cn nnl Ftrrllics mi
<br />civil fir\ uf ro ort hutrdrcd lhouslnd dollr^ (SIOO,0OO). i'r ddilion h lht .o{ .f.onrFn\rtion. d!rogc\ * phvid.d n)r rhr
<br />Sd.rn,n :1076 ofrhc ktrr Cdc. inrcrcst and,tomy s f.cr
<br />$ /"8 lv r?nUu,,-r, X
<br />DECI,AMIIO!
<br />Ihcrch,lmirnund(pcnllryofpcrlurylhalI r liensd u.d( l.o{kiotr of Chrptcr 9 (ommking wilh Scclion 7(D0) or Divnion l
<br />of rhc Busin.$ and Pmicssions Cod., 6.d ny lt.n* n r tull lore i .ltsr
<br />C(INSTRIJCTTON I FNNIN(: (;ENCI
<br />I hcrc$y rnhr!ftlcr Pcndlryofr.rjurr rtur lhoc is a co.srtucrili knding n8.ncy for rh. pc{oi'un . oflhc *ort lor *hi.h rhis lc.nri n
<br />ksucd (Scc.309?. Civ. C.)
<br />lrnd.is Nam
<br />-
<br />Ixtrdci. Addc$
<br />-
<br />A.SPIICANLDI.ELAMIPN
<br />I h.Eby arm ud.. !.dalty orp.ruly onc ofthe folbwn'g ddl&arions
<br />Dcnblilion Pcrmirs Asbc!x,\ Norific.lion Fcdcrol Rc8ulrlions (Tirlc.ro, Pd6)
<br />-RcloiEaj
<br />Lclcrof Norirslion
<br />I cdiry rhar lhc lcdcrolrcsuhlb.s rcg,rdine $bcnosEnDv,l c nol lPplicahlc ro rhh rr+ct.
<br />i?6"nnr,nn, , t," ^n, 'n',
<br />snnl'!d'.tr ahl <arc rharthe ahovc inl'omln,n i!.otrNr.l aeB ro onplywirh allcilylnd counlv
<br />hia;oRc. and Srorc tjr\ rchrins r n b
<br />'ldrn3
<br />.on{d.uon. a hcrcbyaurhorift rcr.schlalilcs oflhh Ci'ydd counly to cnrs ulbnrhc
<br />rti,vc 'mnrn,ncd rn,Nny i,, intpcdbnpt,,x rbe=- ,,,.,€ ltz ltqP,\pDlitut or laenl siltrrlurr
<br />l'rn il( r n.lDriolr:)(t$ u,=TLr,t I Teifl
<br />BUILDING. INSPECTOR RECORD
<br />x.uha.
<br />'*tW>IO
<br />T-Bar
<br />qo/.44/
<br />tt
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