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SITE-WORK DATE ID/SIG.COMMENTS OWNER BUILDER DELCAI{{TION
<br />I hcrcby 8filrm unds p€nrlry.l rrjury rhar I en.x.orIr rn,fr rh. ComrKr,F l-i..orc tiw ror rhr lolk,sins '.rvn (sec?011.5
<br />Bxrincs and Profcsrn Codc): An, Ciry or Counr, wnicn rcqutcs a r^-nnit to constdct. .ltcr. improvc. dcmlish or relst ,try
<br />nru.turc. |)rbrid ik nsuncc- also rcqutcsrh.al)Pliconr for su.h Frn r, filc a (i8md sr c rnr rhrrhcorlhc is lrcn{d pu^uanr
<br />lo rhc rhvisnrs of rhc Conhckn\ Liccned Lrw (Ch.rrn 9, Conmctui'rg wirh Sc.rio. lot{) ol Division .l ol rh. l}usi',.$ und -
<br />PmlcssionsCodc)orrhdr hc.rshc i\cicnut rhcrcliomand thc nash lor rhc allcgcd crcryrrion Anrri{,|&rionrserionTl)ll5hyrny
<br />.llplicd tu ! Frmil suhjd s rhc appli.anr ro n civ il pcnn lt y ol not mrc rh&n fivc hlndrcd doller ( 35(n).
<br />l. is own.r oi rhe popcny. or nry cnl,loles Nirh *r8cs as rh.ir wlc compcnelion, will do lh. rork ffd rhc {mlm n rct
<br />intcnlsl or or.r.d r(tr s,le (sr 7014, Brsims and ltofc$ions Codc ! he Conrracrois l,tcn{ l,* dmr nor 0pply ro !n ox mr .r
<br />ih. rft,pcny shohild!ot inrtrxrs lheB,n. md wtr)dtu\{chk)rl himsclfor hcrsclf.irh$u8h hh or hcr o*n cnrpk,yccs.
<br />pmvidcd rhtrr such nnnl ovcnEnts m mt i.icn&d or o,f.dl lbr slc ll how$cr. rhchuihinsor i'rDmwnEnt hsoklwirhinom )ritr
<br />ofcotr!)bli'n, rtE OBncr Buiu.r qill h.vc rlr bndc. .f p.Trir8 rhor hc or \he dil mr tuiH or irymt rh. tmFny for rhc luqxM of
<br />l. a\ own r ol rhc pr)Nny. .n crclu.rvcly conrrcrins sirh liccn{d colnrrr,G h constu.U h tn)i.d (Sc. 7{l1l. Bu.ircs
<br />ind lhtssionCodc 'lhcConrra.ntr s L,i(cnsc Lrw docs ror rfplrt, .q cr.l [opcrlywho 6uikk or inrr(,vcs rh.rcon.
<br />and who conrmch lor such tmj.cts wirh a Cirntrck,(, lkcn{d nuFurnr h rhc Cont..r.i s Li.cnsc Liw).
<br />-l
<br />uhctcmfl undcr Sccrion
<br />TQBtrIBS:CQTIIENSAIION
<br />DECI.AMIION
<br />I hcrchy afllnn undf f.nrhy of r.rrtrry otu ofrhc ftnhwing delorlrnns
<br />I havc ond wi!lnuinraiD! CcniicalcofConscnl ro Scll-lNUm lar sorkcrs .onlrtrsurion. $ pmvidcd for hyScclioolT([ollhc
<br />bty'r c.dc.l, rhc rcrlqNtrc orrhc wo,l lnr trhih rhc p.'nnr F F.ucd
<br />YlhNc rn,l s'llmrinkin s lc^' cn,nl.nsari,,n trruroncc. os rcquncdbysc.liotr:1700olrhchhorG)dc,hrrhc,r,ti,manccol
<br />rhc $ork ror shi.h rht pcrnir is ir .n M,ro*cn comNnsation itrsurancc.iriq otn plicy nunbcr se:
<br />cariicr Nn R)Pe,r>
<br />I .cnn_v rhdr i'r rhc I'rrfomuNc i)frhc sorl r(n *hi.h rhl\ n nnir t islucd. I $rll nor ctr1plo! r',y pcry in nny
<br />'nMtrcrv, x\h hc.orE rrnjer rolhc w.rkcr conlncn{ri l,ws .r Crlin rtrir. Md Jrrcc th{l ii l shou rd t$o.rc subirr h lhc
<br />trorkcr\ cornctr{lior Dovi\ion\ .i Scclio ]7m ol ihc Lrlrn Cr)dc.l sh.ll. tunh*irh.onlny wirh lnoe rn,vi\i{nrs
<br />WARNIN(;: Ilihto kr {.urc trorkcr $mp.n{ i,n, .orslgc i\ nnh{lrl. rnd rll hjc.r rn.nrrnD$ b.n riml nrmkr\ did
<br />.ivii finc\ up k, om huftlrcd rhou\rn.l dollar (Sl(x).lxD). irj itrlLlirn,n b rh. con .f con,rnsarnnr. daix,gcs rs ttr)vnlcd l'or rhc
<br />::::'Eli4',li
<br />o. 'i.r.{ tril rnn.y \,i.\cl
<br />lI(t\lt\It{)\
<br />I hcrehy atfimltndcr ncMlryotp.rjury rhd I am liccn{n undcr pmvtion olChlprcr 9lc.mnrncing wirh S.crinr X)00) ofDivnn)n:l
<br />or rhc Bu\i'rc\\ d Pnni$i,n,\ Codc. nnd nry licctrrc i\ ir tull hrcc rnd.r'rtcl
<br />o"* J tel
<br />TONSIBIJCIIIINIENDI!1;.AJiI]N.CI
<br />I hcrchy alfirnr undcr pcnrlryofpcrjury lh!r lhcrc n r cotr{nElion lcndins o8cncy lor lhc pcltorn,arcc . r I he *ork n, uhi.h thir p.rnrir is
<br />issucd (Scc lU)7. Civ C I.
<br />kndcas Add,css:
<br />-
<br />AIELICANTIECLABAIIO!
<br />I Imbyollnnundcr pcnrlryotpcrjury onc of th. tolloqing del:trrrions:
<br />Ocmnti,,n Pcnniis Ash.nos Norificrrn t Fcdcral RdgxlDrioi\ (Tiilc,r{. Pmr6)
<br />Rcqutcd ktrf .f N.rif$rhn
<br />-l
<br />rcniiyrlulrhc ltdcral!.sulJri.ns rcEardiDs!\6c{os'ctrrovrlrr. nor ap|licahlc k'rni\ pri,j.cr
<br />rtx)lc nrcrrbmd p0Fny i)r i',\p..ion purFNc!
<br />Appli(xnl or lA€nt Si!unlurc @ ,,,"llalv
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads 4 I nr- -,)
<br />UFER Ground \a)''t?//l /2 T"/w
<br />SLAB Floor 7 -rT I
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq )I .-\
<br />Shear Wall 'o/t?/17 .ru.|I
<br />'itzlrs "W,lb
<br />I
<br />Drywall m,r/t{ -rB ul /.7,1,t,/ti ,ffi)
<br />Brown Coal q.^i;R 'b/tr'n.wi,
<br />lVlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Beq
<br />Deputy Final Report
<br />Enqineer Final Beport
<br />Flood Zone Certif.
<br />FINAL 3/c,t//4 .lffiq,
<br />Certilicate of Occu pancyT
<br />Notes, Remarks , EIC
<br />BUILDING- INSPECTOR RECORD
<br />,-
<br />\,(-,Framinq
<br />lnsulation/Enerqv
<br />Ext./lnt. Lath
<br />/6 />,, lrrt
<br />,0,e4--
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