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BUILDING- INSPECTOR RECORD vDATEID/SIG.OWNER OUII,DEN DELCAR,\TION
<br />I hcrcby afllnn und$ pcnalry oi pcrjury lhar I !m cxc'nrr fro rh. G,nr,.bc Li.cnsc ljw lnrlhe r'ollo*ins rcls.n (Sft 70:rl5
<br />Busnrc$ and Prolcssion Codc) A y Ciry or Counry whi.h icquircs { !.nni io con(rucr. alrs. impn)vc. dcmolirh or rcrii atry
<br />dtucllrd, pri,,b ir\ hsranc.. ath rcquncsihr trtflicntrr for such pcilnilki filc a \i3ncd lrcm rhal h.or shc ir liccn{d P!^ra
<br />to rhc pmlhions of rhc ContEcroa\ Liccnsdd ttrw (Ch{r$ 9, Comnkn.irB sith Sc.lion 7(xx) of Divhion I ofrhc ausinc$ rnd
<br />P,ofcssionsc{dc) orrhar tr orshc ncrcnr/ rhcrclon 0nd rhc hasis lhr ihcsllc8.dcrcnDii('n Anyviol.rionoiScclion?0.lltbyany
<br />,mli.anl loraFrmil subF.lsrtc spplicanr b trcivilprmhyolno! morcrrrtr lrlc hundtcddollur (S50o)
<br />-1.
<br />d{ owftr or rh. p6Fny. or my cnrployecs uirt BrScs as thcir eL co'npcNdn,i. will do rhc sort dd llf, sln,ci@ i\ Nr
<br />inr.nd.d or oficrcd for slc (Ss 701,1. Busi,css md Profcsions Codc Th. c.nta.(tr s Liccnsc f.w docs nor,pply ro ar owftt of
<br />rhc l,opcd, *ho bdildi or itr{ v6 rlE6n, d pho dcs ruch wrk hin$ell or h.r{lf or rhn gh his or hn oq'n eq)Lyccs.
<br />provdcd thor such i,Dlro$mnl\ @ ft inr.tokl 6r oift.d n'r {h. ll th*crc( rlE hdildin! or in'I)rMft.r isoU wilhhonc r-
<br />.f.on{,!criJ( rtr Owmr Builh *ill harc lnc hurden o, pnline rhd hc or \h. dkl buiu or iDpmrc $c pmlleny for rlr pu{r$ of
<br />l. dsowftr orth. pmrcny. imcxcNsnclyco mcrins wirh liccnscd .otu,.r,s h ..n{fld thc proj.{r ( sm 7(,r-.l. Busfts\
<br />and lnrlcsbn Codc: The Co.ta.ror's Li.cnr L.q d.cs n.r rDplylo !nowncrolPror. y wh(, huilds or inrFovcs rhcreon,
<br />rnd sho co acN lor such orercck *irh d Conrtut,( r r liccnrd N^uMr rorhc G,ntacrois l.iccnsc tjw).
<br />I nm crc.pr u.dn S(tio
<br />]yll8rE8EMUENS r0!
<br />DLCI.A.BAIII,IN
<br />I hcrchy uffirn u crpcnlllyolpcrjuryomolrhcfolkisin!d(ld rn \:
<br />lhtrrcn wlll n!' ir d'r a C.nLfictrrc of cod$ k) scl, l Nrc lit $.r lcrr .onEt\rlio . a\ nfiriJ.d fd by se.ri lT0Oolrhc
<br />tjhor Cndc. lar lhc $r li, unccollhc*! i,whi.hrh.Jt'trtiis'\\ucd
<br />. ,ri(r rrlpoli.r- trtrn,b., x'.
<br />>u{o"nLo&ND
<br />_Exttcs:tltb
<br />,lccnilyrhrrinrhcr.rfonmnrofrh.sorkturwhi.hrh'!Nrnrir n isucd.I\hrllnor cmpk,t riy Pdi\otr xt lny nr rcr
<br />y, r\ b hLCo tr suhlc.r r. rhc workcri comFrsirion hws ol CrlilniDir. r l agd rhd ifl fiJukl hcco,rc {'hjcd t, rlf,
<br />workc^ .. rfrctrsar idr pmunions ol Scdtnr ST(x) of rhe l ]rhor Codc. l drll, fidhwirlr .onlry *rrh lMs lr ovisi(trr
<br />IyARNINC l:rilulc n) rcurc *orlcrs comprnsrri(nr rourn'sc r\ unhshl. r \h]ll s,hjccr U,. fkJycr ro dimi ncmlrics u'l
<br />.ivil fincs uI lo o'E htrndrc.l ihousnnd ddllis ddiri(rr ltlhc con orc.tr1Pcnsdn,r, dinn8c\ as pn,vidcd ror rhc
<br />Sccrion]076olrhc l-$or C{xlc, i' cddind
<br />*", - -ffilot/tf2
<br />!.2!!:Mttt!,1
<br />I hcrcby liftrDUnder pcMlryolp.rjury rh, I am li.cns.{ und.r provhion ofChlplcr 9(commn.ints with
<br />ol thc ausircss and Pnfc\rions Code. ud ny licmsu n ir rull lo(c ,nd cflccr
<br />4b164 +
<br />raNu.tslLl.tut t Jtl2t!.!,!tiD!1r
<br />I h.eby aflnn uMcr rEnalry or pcrjury th,r rhcrc is,conslru.rir. bndirya8.myf{rrhcpc omrtu.of thc work iotehicho,isrcrmir i\
<br />issucd lScc. 3tr97, Ci!. C ).
<br />ATPI I( ]ANT I'It(]I.ARAI'IoN
<br />lltrcbydltnundcr pcnrlry olpc.ju.l. c olrlic fi,lk'wnrg dc.lxhl ior\
<br />Dc r)lirn[ Pc' rir*Asbcnol N.tilicrri,n, Fcdrrr R.grIrnn,s flir[',11r. PI$)
<br />Rcquncd LrllcrolN.lifi.rri,)r
<br />I cdi! rhrr I hrvc rc rlris
<br />onlh'r!\ xlshr.lrs.mlii
<br />rtrvc rlctrri.ncd pmpcn, for ii
<br />i{r! {xrc rhri rlt rh,v. i'rla' tuir n.om(r lrprcclo.oDrnlrwirhrllCiryrtrdCuumy
<br />tr{ru.riur. rn(lhcr.h) rtrrhori/c rr|,r\cnturi\cr.l lhi\ Cirr ind ('.unrynr ctrrc. uFrr thr
<br />,\ppli.nnl or ,\gcnl Signrl -"*eptf tb
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFEB Ground
<br />SLAB Floor 4/mlp vv4h-tdz-/
<br />Subf loorvenVlnsu lation
<br />Roof Shealhinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall a/za l*6tltt>*'/a
<br />Ext./lnt. Lath I
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL q/p/tt Enh-vr+-/i2
<br />Certif icate ot Occupancy
<br />Notes, Remarks, Etc.
<br />SITE.WOBK COMMENTS
<br />lr
<br />_l ccnilirhirrhc rid.rJrcgDhiotrs rc8.fulin! nstE{.s rc r,vrldrc oorrtp iclhlc t) rlrit fn,l&i
<br />NS
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