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BUILDING- INSPECTOR RECORD
<br />co ENTSSITE.WOHK DATE ID/SIG.OWNER BU!LDER DELCARATION
<br />I h.rchy allirm undd ,cnrhy r)f pcrjury rhal I m cxcnrtl riom lhc Contlcro^ l-i..nr tjw ror rhc rbllo*irr8 rca$n (Scc 70ll5
<br />Busincs lrxl Pn)icssion Codc), Any Cn, or Coriry *hich rcqrirc\ a Nnnir b con(dct. rlrcr. nn,novc, dcmlish or rcI,ln $y
<br />ntucNrc. tritr ro irs itsurtrc.. aho r.qnn.srhc amli.rnr for sDchtcnnir to Ijlc o signcd (0icrrcnr rtd hcor\hc i\ ll.c0scd puNuanr
<br />ro thc [ovkions olrtE Conhcrois Liccnscd lis (Chalrcr 9, Grhrnn.ing wirh sc.rnr 7o0l] of Division.l of lhc Btsinc$ lnd
<br />Profc$i.n\Code)orrhrl hco.lhc ncicnur rhcrcf.omtrndrhc hrsi\ forrh.ollc!.dcrcnprion AtryvnnalionoiScdi{,n70-ll5bynny
<br />arplicnnrrorapcnnnsubjftarhc,mli.n lo { .ivil p.nrlry .r mr nrr. m rivc hu drcd dollm ( $500)
<br />-1.
<br />rs o*re, of lnc nmncn y- ,n nrt cDdo)tc! *irh wascs !\ rhcn \,l. c.nf.nqr ion. will do rhc s,trk ord rhc $tur@ i\ :xn
<br />i'ncaddl orofi.r.d f(r sdlc (S&.7O1-l. Busircs x Ptufcsion{C(rlc Thcaonr.doisl-iccnscliwdoc\noraPtlyh.nown.i.f
<br />rh. rF|Eny $h. hui[\ or inlpmls rtEron. adwho des su.h wrt hiDscllor tcr{lror rhn,rsh hn or h.r own cnlloyecs.
<br />pn)vidcd rh su.h inorcrcmnh e nor i,ncrdcd or.llcd] tur elc.It h)rc(rrb t^'ildilra or illl|rorcm.r is v)ld *irhi', nc ]rir
<br />of..trlikri{r rtf,()*ncr BuikLr willhdvc rh. hrrd.tr ofpn,viq rh, hi.r shc did n.r hrih or nnnmrc thc pmlqly lor rh. nuqx,\cof
<br />I.a\o*ErofthcF,p.ny.a'ncrch\ivclyconradinE*irhli.cn\cdcotict'6h..tr$fl.t(h.pmI.l(Scc?(!,r.8u\im*
<br />rtkl Bnfcsbtr Codc ThcCotrtrrctor's Liccnsc Lrq doc\ nor rpplylo oo*ncrol|xrrc r sho hnilds or nnPnrcs rhcrcotr.
<br />ud sho conhcrr for \uch proF( $irh ! G,niEcb(n li.cn\cd ld6uMr n, rhc Co r.cr, s l.iccnsc l-otr ).
<br />I rncxcmt, u cr Sc.ri /ru(-.-
<br />l,ulllAaauoN
<br />I hcrcby !flimuodcr PcnalryofrEriury orc otlhc iollowin! dcclararions:
<br />Ihavc dtrilltrrinrtri,ractnific.rcolcorsctrrloSclfln$rcn{*orkcfconlpc\rion,,\providcdtubysccrion.1700ofrhc
<br />bhi,r C.d.. for rhc l*rformn.c ufrh. so* lorqhi.hrhc Frmir n Gsucd
<br />-lhav.
<br />rnd willmiinhin slnkrrr .onfrn\rriotr itrlurrmc. rs nqdn(dh!Sccii.n.17(X)ofrhclihorCodc-turrhcPrnrm r.or
<br />(hc *ork f{tr *hich rhi\ pcrnii i\ i\\ud M, (o'kc^' Lrnnpcn\rriu, in\uirn.c.micr.rd Bnl.y nun$s nrc
<br />-l
<br />ccnifyrhar in rhcFrlorm'trccoIlhc work for whichltis pcrmi n hslcn,I \hallnor cnrkJy ylcaotr in rnynrnncr
<br />$ * (, bcr,E sxblcd ro rhe *odcr\ omp.n\dir. laus or CrliLmir. nnd l8rcc thlt if I \nould lEcoft sll,jd ro rL
<br />workc.o'nFnsdri,nln,vhiotri.fSc.rion17fi)orrhcLnhtrc(dc.Ishill.nflhwithcomnlywirhrho$F)vhnnts
<br />WARNINC: Filui. ro s-urc qork s' co,qxnsarion .orcm8c ir unhwful- and \hrlr subAr rn cnDl,)u h aininal |c.altts nnd
<br />.ivrl lln.\ uti b oN hutrdrcd rhouldtrd do lld, ,1lri,.tl(]l". In rJdirn{, !, rlr 9rr ul ,r 'rl tr{,tr{r, dJtuer{ } norincd fo_ Ihc
<br />^ --r- -a
<br />,,,*",,j-.1)n,Lo" /l4zz-;
<br />IICTISED-(ONItrA(]UB
<br />DECIdM.IION
<br />I hcrhy trfilirn utulcr pciahy.fr.rlury Ihrr , mr l(cn*d undcr pr.visiotr oa(-h.!rcr 9lconurncing {irh Sccrid 7t[O) orDivision:]
<br />oi rhc Busincs ind Profesion\ Codc- ud my licc!\. is in hrllro(a dkl.lr.cr
<br />IONEIIIICIII}N.LEIDIIG.A{iDNCI
<br />I hccby amrm undcr Fmlry of n rjury rhar lh.rc is ! consrocrbn lcndins ascncy l'or rhc pdronnncc ot $. wort lb, whth rhis Iarn r k
<br />hqudd (S...1097. Civ. C.).
<br />A-PlUCrrNfI)[CL XAIIg!
<br />IhcrbtnlfinnunJ.rFndliyorrcrruryoncol th.folhqnrgdccldfl ions
<br />I)c'nolirbn Pcrnik A\hcio\ Notifi.rrion F.rlchl Rcguhrions (TIlc,1l), Pan6)
<br />Rcqtrir.d lxtrcr of Noriric iJn
<br />-lccnilyrhd
<br />rhc lcdmrl rcsuhr iqN 'cslnli'rs a\h.no\ r.nn,vrl rr. Doi fpliuhlc !)rhi\ !r(!ccl
<br />-l
<br />ccdilyihd I hrlcr.rdihi\ rptlicnrionmd {Icrhdrhc.lr'\c rlonD n,nh.omcr la8rlrhcotrlPlylvilhnllCirrrtrdCotrnrY
<br />oi{hnrNcs xnd Srrlc I-r\s ft]lr'trg h h,ldr! .otr(ru.ltrnr.
<br />otc mnrinncd nmPcny ror insrS(n
<br />ApDlkant o. AEenl slrMluE /
<br />y onrlirm rcnrcscnhrivcs o h Cny an{countylo cnrcr u,i.n rl.c
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathing '//1vJ 0,
<br />Shear Wall I
<br />Framinq
<br />lnsu lation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Beport
<br />Engineer Final Report
<br />Flood Zone Certif
<br />/:\
<br />FINAL (trlrt {v?\,*^,(? )./
<br />Certificate of Occupancy tt
<br />Noles, Bemarks , Etc.7+.
<br />o
<br />A/,
<br />Policy Numbcr:-Erlncs:
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<br />P.mil.. nan. (priIo:
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