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SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARATION
<br />I hcrcby rflinn und.r Fndlry ,)f p$juiy ihd I m crclllpr tion rhc Contrcr{,n l-i..n\c lre ,{tr rhc ii,lk,wd8 r.r$i (S..70t 5
<br />Businc$ atu Pmitssion Codc): Any Ciry or C.xnrl shi.h rcquir.s r tf,r ,ir h .on{dcr. rli.r. nnri( r. d.imlish or rut .n any
<br />(rucrlrc- pri.r ro irs hsuancc. !l$ requncsrhc atnlicitrl tbr such Nnnirro filc 1si3rcd stltcnrnt lh tEor shc h licctrsd puruo
<br />ro thc prcvisiors or rhc ContrcroCs Liatrscd trw (Chlprcr L G,m,n n.ih! wnh S..rion 70OO of Dirisiun I .l rh. arlms d J
<br />llolcsvonscodc)orrharhcorshcscxcnllthcreIiomnndlhcbasisrorrhclllcgcdcxcmprrn.Anyvmhrionofsccri{rn71r.li{h)'ry
<br />trrplicrnr tu,pcnnn suhjsls lhc arplicunr ro !cililDctrrllyoinot mrc lnrn Ive hund.cddolltr (Sslxj)
<br />-1.as
<br />orvrcroiIhcfmPcnr.ormycnr oyNs wir lr Br8cs rs rh.t slc .o ll\rN otr.wrlldorhcs.rk drhc(nrlurci\nor
<br />idc Ld oroL..cdlarsalc(Sr701.l.Brsim\srndltolt(i.nsConc:lh.Conrradoisl.iccns.li$docsnorrpplyoriosncror
<br />rh.F)tf,rry who huikk or irqo(n$ rhcsr. a whodocr{chnnkhinr\clforhcrsulforrlton8hhis.rhcrosncnd.yccr.
<br />[ovnhd rhar such i'nto\rrr h,r r inrctoIcd o,llrul r& sh ll k)scvtr. rnc 6oikli'r3 or i'nprtrom h\oh wirhi"nnc lrr
<br />orconrl]lcrirn. rl{ owner lluildcr *ill harc rhc hurdcn ol'rrovin8 rhd h. or $c nid ml hri[].r iryr.rc rhc pma.ny for ihc purF){or
<br />l. Aowncrotrhcrnpcdy, rmcrciusilclrconrrrring wnh liccns.d c.Dtrrcr,)F t, con(ruclhc Iojccr (S.c 7(lJt, au{ncs
<br />lnd hafssion (odc Thc('onlmcloisLicctrsctjwdoclnornprlyror osncr olFpciiywho buiklr or nnnrovcs lhcrc.n.
<br />and who ..nktu(for ru.h pm]cd r uirh a Conkrctn( \ ) li.cnsql pu^ud nrih.CoftKtr's l-iccn{ t ,s)
<br />lmcrci! utrdciS..rir
<br />*" ) {/n?/8""".",
<br />![!!"1]! -lla!Ihcrchyainru crytrdlryol rErjury on. olrhc ldkNin! dNldrari(nl
<br />-l
<br />hi$ d will mrinrin rCcdific.rcofcon*nr h S.lf lnsrm f(tr w.rkdJ.onDctrsrtion..s pn,vidcd for hySclion:lT0Oollhc
<br />L.txtr Co{c. nr rh. lcnalmft. ofrhc *uk fui whi.h rhc pcrnrir k i\\x.d
<br />I hxu trnd willnuinhin workcF co r.nsrlioniNurrnc.(\rcquncdhySc.lior:l7lx)oirhcl;{xtrCodc.r{nricpcrtuntunror
<br />rhc work ror *hich lhis pcmril is i$ucd. Myqorkcrs omncn$riotr irNu.nncc cinicr lnd loli.yruorh.!!rc:
<br />Cartcr-
<br />lccnilirhrr inrhc |xrfonMKc{)f rl[$.rk r(n shicI rl,is ncrmirb n\ ro hcconr sul,jccl ro
<br />'hc
<br />sorlcn comllctrsihotr la(s.rCrlir tr
<br />{ortcr coarFnsdi.r pmvnions niSccrio. J7{x)ol rhc litrtr Cdl..
<br />ItAR\IN(; I..nl r rc.n'r s,trlc,i, nF.r.ni,ri rr.T!c i. u
<br />civil lrtrc\ up t, otrc huidrcd rhou\rnd dolln^ lSloO.(Xn). in addir
<br />i\ i\{'c,l.l \l llnorcn .yrnJ,prr\nrinn ym tur
<br />ir. d 0ltlccrh il lrhoul(l hcc(nN suh,cclr. rhc
<br />I dull. fiinh\ih.onrfly sirh rlDr provi\ions
<br />nlxwtuI rnd sl !l {,l,Jccr nn unflo)$ h (i'nitullf,nrhts nl
<br />onl,.nvrn,n. dintr8.s rr provid
<br />s..ri, 11176 olrltr Irlrr Lir. trr.r.n r tlr[f'nrJ \ ]r..,".,*1hg//9,,,
<br />IhcrcbyafiirmunderpcnallyolpcrjuryrhdInnliccnedrndcrprcvhion.lChrrrcr9lcornEncinswirhSccri'n7O0O)olDirision.l
<br />of thc Busirc$ a Pmlcssions Lidc. ard mv liccn{ is ii tull foi& ad cficcr
<br />cl)$ilB.ucrll)Nr[NDtlc-aclitrr
<br />I hcrcby uflirn undf lcndlryorpcrjury rh rhcrc ir,.on(tucrion lcndinS agc..y ror lhc Fdr.rmn.c orihc qork ti,r *hi.h lhh ,l.mil h
<br />issucd ( se. :1097. civ. c ).
<br />AISLII;ANfIECIABAIIIJ!
<br />I ts$y afllm uM.i Fnalrt ofFary orc ofrh. follo*i ! d& lrar i,)n\l
<br />Dcndnioi Pclnns Arhesros N.rincarion Fcdclul Rcsularions (Tnlc 40. l,tul6)
<br />-Rcqutcd
<br />tf, llcr of Notifi cllbn
<br />l.c'i'l,vrhrr rlr lcdcrrltu!ulxri"i\r+dJi'rg r(r(o\ rcfn,vrlJc iorxtlfli.rhlc k, ihs pn)ic.r
<br />-l
<br />ccnify rhd I h.vc rcad ihr atrli.rrio. furl r.rc rhdr rh. rtr'v. inli,rmrion is.onct. I +rc 1o conDly with rllCnyind CoDnly
<br />odir0nccs udSrlc l-assrcldrirylo huildi{ cof{ru.r6..
<br />"nd
<br />hcrchy h.rizc rclcsctrt ivcs oflhn Cnyand Counly lo cnrcr upon lhc
<br />ihnvc nf,nr'ok,i nmrny to n(nNriu
<br />Apprirmr or l*or srsnorum (
<br />P.mll& nnne tpri.l):
<br />^*V/oSt//g
<br />Set Backs
<br />Forms/Steel/Holdowns I I __.-.
<br />Erection Pads tIrfir.a 'ehr )
<br />UFER Ground
<br />SLAB Floor
<br />Subf looriVenVl nsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framinq lt/1,r /*>.\xt
<br />lnsulalioni Energy
<br />Qlywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lrlasonry
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />FINAL z/.2<t /ta F- rrulv ./d2-
<br />Certilicate of Occupancy 7I
<br />Notes Re marks, Etc.
<br />BUILDING. INSPECTOR RECORD
<br />Pool Fence
<br />T-Bar
<br />€5_
<br />lrnd.,'r Addrc$
<br />I
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