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SITE.WORK DATE ID/SIG.COMMENTS OWNE'I BU!LDI]R DELCARAlON
<br />I hcEl,, lrfirn Mder l{nilly ol pcrjury rhrr I m .rcnr nun lhc Contrkt{ l-iccnsc u* ri, rh. rollovin8 rcaq,n (s.c 70ll s
<br />Bu\in.s\ rnd Poli$ion Codd) Aiy Cir, or Counry *hich r.quir.\ r lEi,nir k' ron{ .r. .lrcr. itnPnrc. &'mlish 'r rcIJir lnv
<br />sdcrurc. p orlo ils hstraftc, also rcqute\ lhc lPllicnr rt* ru.h |tnnirl,' rllci \i!trcd (.lcnrnr lhrr hc.rshc i licensed ntr^umr
<br />t' lhc tmvni.ns oi rnc Conlractr's Liccned bw ichiPrcr 9. Co nncrcn8 wirh Sccrnrn 7uD of Divhion .l or rh' Bn(in's rnd
<br />Pnnassions Codc)orlhar hcor\hd (cxcnn lhcrcl'ronrflnnr[c tlnN rar rhc trllcscd cknltri(nr' Anv riollris.r Sdion 70]1.5 hvanv
<br />rptlicrtrr for a lernir su6ach rhc umli$nr t' r .iv il Fnrlry oi nor nuc rhrn fi$c hu reddollr\{S5tD)
<br />-1.
<br />!s owncr ol rhc nmFny. o. my enulo,6i wirh wn8.s s. rhcn $k conP.nerion. will do rhc wori .Jd rhc stn!ft n mr
<br />inrcrdd or dffcrcd ror slc (Sc 7044. Brsiftss dnd Profc$bns C(xl.: rh. CoMadoi r L,iccnr Ljw docs nol lPplv ro ,n otrncr ol
<br />rhcomlEny wlF htrilds or inur.ts rlL]Nn. !d wtx' dG {ch Rr* himtllor hci\clfor rhm!3h hk or hcr own cnDlove€s.
<br />provid.d rhat such inDmwmnh m ml inrcndci or ontrcd for sL lt lx'scrcr. rhc huiklinBo. irpmvcmnr ii sll wirhir onc,s
<br />;fconpkrt'n. lll Owncr Builtq *ill havc r,r blldetr ot Proins rtun h. or $hc dil ml tiikl ot ir{'ove tnc pmFnv ror 'lr
<br />puqnc ot
<br />l.rsoeftrolIhcprcleny.am.r.lusivclycotrl.rcri[Csirhli..\cdconrrcror\k]conitu.trhrp(+cr(Scc7014.Au{ncss
<br />.nd hrl6\ionCodc: Thc Contaclois l-iccns. Law doc\ tror rDnlyb mo*Nr.lnt0P. vwfi.buildsorinrprortsthcrcon'
<br />nd who co mcF f.r sd.h Fmicds wnh u Conhcro(t li.Ln\.d Pursu n, rhe (i,nhr(r\ Liccn* Lf,sI
<br />I a'ncnnlPl undcrSsrio B & P.C n)! r[irr.Nnr
<br />lloRKr RS' (l(llll PENSATION
<br />OEC',Af,AIIAN
<br />I hcrchy ran.nund.r r.n0hy of lcrjnry 6nc ol thc rollowin8 dccbtarions:
<br />-lhakmdwillnui
<br />dnaCcnificatcofc.nsctrlroSclflNurct{,workcrs clmpcnsrn,n. rs Providcdl'orbysdrionlTlx)olrhc
<br />L,hor Codc. for th. p$fornEnce oflhc work r.r *hi.h lhc t'cnir i\ issx.d
<br />I hrvc andwill mrinrdn workcrl comp.nsaliqr insurricc. rs rcquncd hrSdion]Tmoirhc l-abor c.d..lor lie Pcrronnxn" 'f
<br />rhc work t r shich rhis rcrnnl is issucd My w. $ omFtrsrtion inrurrn c .,nicr d Plicv nt
<br />'bcr
<br />rc:
<br />I.crill,lhrr in lhc pcrtunmtrrcoltlrc sork lnr shi.,rrhn Nnn i\ isL.d.l \lHll { c rpl.vrn} l^-^oi ir dnvm!nncr
<br />\) rst, hc.of,rc \trlB.r r,lhcsorkcrs .otrlnctr\arur hw( ul ( dlilnnrir. rklrlrcc rhrl il l\lnn'l(lh.rtnrc stuc.l brh.
<br />sorkc^ comp€ns rn,n pmvnions of Sccr im lTm ol rhc htFr Oxlc. l
<br />WARNIN(;: Flilure to rcnrc workcr' coNPcnsrrion colc(8c is lnlr
<br />\hall. li,r rlrwllh conrly *irh
<br />uwitrl, ,nd \hrll sublccr rn
<br />n b thr ..s olc.nDcnlnrrh!r\ Dtl (lolr'\ lllri)rxr) 1r
<br />DrcI.AMIION
<br />.cn*{ utrdcr prcvi\bn ofCh{'rcr 9(conrntnci'rg wirh Sarion ?0U, ofDivisio! lI hc'.hr- rlllrn,und.r |r nlrtol 1).'i,tr)
<br />of rhc Bu\itusxnd Prorc$ions Codc. iJti fry li.cnsc is lull lorcc ml .ffccr
<br />I hcEhy Jfinrundo p.n,lry ol pcrjury rhlr I
<br />k('c(lrs.. 1097 Civ C I
<br />ion lcn.lirg rgci.y l lhc p.nnmn c olthc Notk hr which rhis Pcrnri n
<br />aPpl lcaNtlllt(ll {R l'loN
<br />I trrhy.fllan undcr pcnally otFrjory onc oflhc nnbsi',s dcclnnrnn:
<br />Dcmolinnr Pci,nin"Asb.slos Noliii.rridr Fcdcrrl RcBuhlior ('l irlc 40. I'M6l
<br />-Rcqunrd
<br />Lcncr olNorilt{ri,n,
<br />rclulir(nN res:trdi',x n\ltnoi c tr)vL'lr. ntrr|fltrhl. ri (h\ P(Ird
<br />iorn rRL{rn: rh rh.rhtro d,l I rSrN k, c.nul, qnh nI Cily rnd ci)r rY
<br />)/t4 /l4u/l
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathino
<br />Shear Wall /,
<br />Framinq 1-211r k(v
<br />lnsulation/Energy \4
<br />Drywall 1-25-16 X.u)(
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It/asonry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Ceftif
<br />,a
<br />FINAL lc-lt-lV t7Certilicate ol Occupancy
<br />Notes, Remarks, Etc.
<br />BUILDING- INSPECTOR RECORD
<br />UFER Ground
<br />T-Bar
<br />vJLlll
<br />Policy Nonhcr:-ErPtcs: =-
<br />I cnd.,'r Addrc*
<br />-
<br />f-r
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