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OWNER OUILI)ER DELC RATION
<br />Ihcr.hyrl]nnxnd.rF.ilry,,fpcriuryrhrrIa.x.nlPrfmnrhcContacrrJLiccnrcLrwforth.folloqin8rcasn(Scc.7()ll5
<br />Itusinc$ id Pr.lcsiotr Codc) Any City or Counry w[ich rcquncr r timir ro con(rucr. rlrc( improvc, dcmrth or Erut ]n,
<br />drucrlrc. flinro iis issumcc- aho r.quircsrhcaprlicanr lbr suchlInnirro r]lca sisned irarcmnr rhrr hc.rshc h li..ns.d I)uNdr
<br />ro lhc prcvsion\ ofrl* Conta.roas Liccnscd ljw (Chr cr9.Co rmn.fl8 wfh Sc.ri TUX] of Division I oflhc Ausinc$ ul
<br />ItolcssionsCodc)orttulh.orshciscrc'nfllhcrclronrrtrdlh.hnsGtulhenllc8cdcrcmplion.Any!i{r0riorolsccriu'70:ll5hyd{v
<br />trprlican' tur pcnnir suhjcch ihc appli.,nr r. acivilI)cn!llyolnol nmrcllun llv. h!odr.d dollar\(i5(U
<br />-1.
<br />r\ o$ncr of lhc pnrlrdy. or my cnrployes uirh wl8cs as rhcn snc compcn\ll ion. sill do rb. $o,k ud rhc dndm n nul
<br />i .,klrl or oJtcrcd lnr 91. ( Su.7O4-1. Busirc$ ind ftofc\\nrn\ C,xlc Thc Coikr.ttr\ t-i..n* Llw Jocs mr amly lo an owncr of
<br />rhcpn,p.ny Nt huilds or inDmvcs Irrren. nd wk' d@s such wlt rrtn{rl o. hcNll or rhroush hh or hq own chpk,y.c\.
<br />providcd rhrr ruch inrr$rcmtrrs N mr idcidcd .i ollcdl fnr {'lc ll how.rar, rhc hikli'i! or inprcvc r.r is *rd wthir .rc yc.r
<br />ol.ohplcri,n. rlr Osh.r AuiHcr *ill hrcc rhc hurdcn ollroviog rhi ,r or +c dil nor brild or inrpD\. dr poFny for rtr purll,{of
<br />I. $ o!rcr or rhc popcdy. r'n cx.lu\ivcl, conrn rirls wirh li.cn*d .ontri.bn tu coniflct rh troFlt (S.. 7Lrr,r. Bs ncs
<br />md lh)fssitr, Codc lh.Coitrcktr s l-i.cnrc La* docs norrtplyt, anosncrolrn)It y Rho huildsor mpmvcs rhcrco..
<br />!.d uho conhclslor suchrnjccGBirha Co.rrudo(I licctr*d prr\urnr rorhcConr6cror'!l.iccn\c liw)
<br />f{'l 8 & P C. r'orlht r.rn)n
<br />DE(IANAUON
<br />I ltrch! rlfi'rutrdcr pculryof ncrjuryoncolrhc lnlbwi'rgdccl(arnn,s
<br />-I
<br />have ud will roinrain a Ccnifrorc oi c{,nrcnr ro Scli I nsurc r'or *oricrr' comren\d i.n- u\ !m!id.d r bys(_rion1700orrh.
<br />L'txtr Codc. {or lhc lcrloruncc oi rlrc work rbrshich lhcr.nnii h i\sucd.
<br />I htr(c nhd will nii'nri sork$s.oniI.trsrbnin\rfu.t,r\requtcdbtSc.rn,n:17(norrhcLJh.rC.dc.forrhpcrlirniNcoi
<br />rhc sork lor whi.h rhis Frnrir i\ kscd Myworkc^ .onpcns.rion iNurM.c.ario rndFlicy nufihcr dc:
<br />l.cnily thd ii thc pcrlornuncc ofrhc work ld qhf,h rhn r.rnnl is issucd.lshnllnol cmrloyanypcrsr inatry nratrmr
<br />$ ^ lo hc(,m subjccl ro Ih. sorkcr( compcnsnri,,n h*r olCllifonri!- and as(. r1fl ir I \houl/ hc.ont \uhjcd to rhc
<br />workcn conrpctrsrionpmvhion\olS$rion:l7rX)ofrhcIltnrCnd..Id l, fonh*irh .o +l! trirh rlxr$ l}nvhio.s
<br />WARNINC r{iturc to sccurc $orkc6 or.pcns nn covcro8c rs unhsrul. and shrll \uhjcd !n cnflortr t, oimiMl Fnaki.s 0nd
<br />cieil ftrc\ uD t. onc hu en rhousrDd dollus (Sl(xJ-(x)O). in lddirio xr rhc co{ orconrFnsrri. . dr'nrlcr rr t'rovidcd ior rhc
<br />Sccrnnr 1076 olrhe Lah)r Gxrc. inrcre( lorl llrormy r lccs
<br />,.,",- rlSl E nrr,n*,, X ht\,u$ )r,,.-
<br />uc[Nllol;oNl3acla.BDEI:L$ IA!
<br />I h.Eby rilirmundcr pcDrllyofDcrjury rhar I rn liccnBl udd l)mvision ol(-hrprcr 9 (comn*ncil8 eirh Sccrion 7000) orDiv(i,)n.l
<br />of lhc Brsim\srid Pn)fcs\tun\ Cod., dxl mr liccn* i\ in frllfitre dld cflirr
<br />Conlmctor
<br />caNEraugu0arENlu&;-efflrl
<br />I hceby afirn undq Fnrky of pcrjury lhal thcrc k r connddion lcndin8 asctrcy r'or thc pcrforroncc .f rh€ eork fttr *hi.h rhis Fmir L\
<br />issucd (ss.3097. civ. c ).
<br />Ircn'l,vrl rrhr laJurlrrFUhr(r \rc!r'din!x\lrn.\rrntrrrlur orrft,l'.rhl.(orINDr.i..l
<br />l!,lltccnityrhd I hivc rcad rhis .pllirlion d (!rc rhar rhc atnvc inlonnnrion hcarccl.I aEG k, onrply * irh sll Ciry rd coxnry
<br />odinrNcs and Sralc tiws Nl,riry
<br />'o
<br />tNildin8 consrd.rion. JId hcrcby dhorizc rcprc{nrriEs ofrin Ciry od Counry k, cn'M ut'oi th.
<br />,,1!)r. inril(trrd t)r,Nnt ln' nr\lI.[tr' t ,t)o\.sL@
<br />14trJt{ -I*rl vil
<br />SITE-WORK DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erectron Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathinq
<br />Framino
<br />lnsulation/Ene rgy
<br />Drywall
<br />Ext./lnt. Lalh
<br />Brown Coat
<br />Ir/asonry
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />'1 --JFINAL7 -lg -/a Jl't)E K//)
<br />Certiticate of Occu pancy
<br />Notes Remarks, Etc.
<br />-)
<br />.\u,licn l or l\xdl Sis ,h'r.
<br />r'*r,i,." n-r.,r;n,,, K
<br />,","zEf L8
<br />BUILDING. INSPECTOR HECORD
<br />Shear Wall
<br />Pool Fence
<br />CaFjcr:
<br />AIPI.ICAILDEgL}SAIION
<br />, hcrcby dttm undcr pcnully or rcrjury om olrhc,nllowire dcclarulion\l
<br />D.flnlirion l,c.rnirrAsbcsros Norificorion l:cdcnlRcsuhrions (Tirlc40, Pan6)
<br />-Rcquncd
<br />l.rlcr ol Norifi calhn
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