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SITE.WORK DATE ID/SIG.COMMENTS OI{NER'UILDEi DELCARATION
<br />I IEEIy .,rum un&r Fulry or Fr!ry rhd I d .r.nfl nbm rlE Conlrrlm Li.ns L!* ,or tlE foU.twbA ,en (5...7011.5
<br />auiBr .,n kof.riix Cod.) Any Ciry or Coudy lnth rqliB r ldtri ro mdru.l. .!6, itrprDE &mlirh o 'q.ir dy
<br />srrErE. FB ro ir! irtlljc. .!o rqliE! rlE rpplirr lor Mh Fmr ro a'L t siSEn rd.!E!'r rh, lE or iE ir lidEcd F,sta
<br />r. rh. pmwions of rlE conrr.ch r Liensn Lw (chaF.r 9. con@Bios rirh sdhn ?000 of oivirbn I of rh. Buircs ud
<br />Pmf.sioN Codc) or rh,l lE d nE ir ctcn$ thdcftoE r.d th. h{sir ior lhc .lLg.d cx.mplioi. A!, va.Lrio! of S.crbn 7011.5 by ry
<br />4plk. f6r . Fmn sbFds rIE .pgliur b r civil FEhy ol ml tut rh.n fir. hIid,.d dolir ilroo)
<br />-1,
<br />$ o*ftr of rrE ,r,F ry, or ny crr'phF! wilh w.g.* rr llEn sL d,nFns i.n, will do tlt s. !,n dE rtu is ml
<br />inrcnd.d.roficEdforrhlSe.TO44,BusiEsundProf6rionrCod.:TlEConf&loarLi..nFLaqdE!nolapplylouow*rof
<br />ltt FoFny wlb hrill! M inFbB rt6( !n eb dGBtl qrt hin-lfor lEslaq rlNlgrrhir h.r o*n.nvt F.s.
<br />p.ovij.d lh.r trt i.snEtul! e ml idn n (o,tritd t* rl Ii,rMw. tll llir,tB d ir+.erE r i iU winnr ( F,
<br />orMphrb,\ llE O\rEr auih.r $ll h,E tlt hnl.' ofFovi,g lnd lt d,E dii or hiild d inpltw lll Flpaly lor r F,Poiof
<br />_l- r o*E or rlr F rarr. m.r.lnrikl, mn'MinS rirh li.r,a.d ..d*lc lo oa{nx! llt piDF (Sc. 7oa,a, BBjl6
<br />.rd PtodcsmCod.: Tn CorrBlors Lixnr U,{t(E hl rpt,l, to uowF ofFnFdy*no buihr or inpDEr llEEn,
<br />od *ho €nrEk ru, trh pot$r wirh. Conrtuonr larnEd BrlMr lo rh. Col!|Eid . La.M h*).
<br />-l
<br />m crcnq uid., Sdrir.-
<br />ITIrAf,E&I.I;OMIEIIAIIONlElldxAua!
<br />I h.rchy.rtr uftLr IE I'yof Fll,ryoE of tlE folb*iry dc.l, .N:
<br />Ih.kdrn*i mrhin . Ccd iararc of ConEnr h Sclf'lnruE for turl6 convr.dio.. a FDvildj for b, Sclnn ]7fi) of rlE
<br />L,bo, Cid., ror rh. p.rfomB! ol th. wort ior whi.h th. l,crnril i1 isslcd
<br />_l h.r rd uill mdrri. mrt6 Nn+.Nr$r iBffi.. rcquiEd by Sali,n l7m of dE Lrrrr C.d.. ror rlE Frroffi.r
<br />rlE hrL a.. *hihrhii Fmir B (rEI My sort6 onFMhn iffi ffi.t,n lbl.y mmtEr e
<br />.-*, t$.f2 c",ro. t^s. F*^i
<br />,",*,n".* - A?Zlatg('zttflzz
<br />-l
<br />rcniltthcl inlhc F.rforrum.ofrlE *ork au !hi.hrhir pctmir is irsudl,l shsll nol.n9loy any ll..mn in..ymnncr
<br />$ itioharm bFriorh.m ds onp.ndbn L$of Crlifomir t ri.sr rlut if| {Dnld bc.om $b}xl loll!
<br />Enc.uFMto.prcvnirdofsdi,nlrmofllEL.borC.d..Iidltdnwhh@rplywnhrbEPDvirbnr.
<br />wAXllINCr FlirE ro m mrt6 oqEB.rbn @mr! n utrh*fril .!, srEI $bFd .itt,bF lo ainnll Frlir td
<br />civil fin.s ut ro oE hu.dEd thous.d dollu (11m,000), in lddirion !o rhc coi dr.onlEnslion, dmScs !r Frovil.d lttr llE
<br />s(rion 1076 ofltE L!tur C.d.. irlcEsl rnd arlorrcy s fe\
<br />^,.. 1/6 /Z)
<br />IIEIIdEAIIQN
<br />I tErcby .ltrn un&r IEm[y of Ftury rhd I e liuEd lndcr Fovi!i]. or Ct pis 9 (mlmxin8 lilh Sa:1bn 70U)) of Divtion l
<br />or rlE BuilK.,!d PrDf6si,ns Cod.. !n ny li.trE n h fuu foc cn.lYtr
<br />.n**.*,, 'A + C
<br />D.,. iulzr v+3 L9t q
<br />N--s.*lne s@
<br />IITNSIII]CDOIIENIINIi.AGENII
<br />I h.irt r trrm u'ncr It liylrFrrnryih, rhdr ir r6deli,n Lndlg t8.By for lh. Ff(lllrEN ol rL mrt ror shih rhB tEd 6
<br />ssr.d (sa 109r. civ c )
<br />LrLLr'rNrm:
<br />A.EIIICAII.DESIJSIITAX
<br />I ho.h, !iin. und.r Fn.li, o{ Frjury om ol rh. rollo*i,8 d.rlasl ionr
<br />Dcmhion Pcrnik-AstBros tlorifrrbn tu..1 Rc3uLti,.! (Tirl..t0. Pd6)
<br />-R.rluirn
<br />krtd 6f fioritdraon
<br />_l cnify rhd E lcd.rd Elulr! bn. m8rdin!.rh.slos Emvd N d'l {pltlblc b fii, trcirl
<br />L/d 'ry
<br />rh, I lIE Etd rhs .!r rlrbn sd n.r. rh4 dr at$w inforibrion n codid I rlr ro o.rpty rnh dr c , .rd counly
<br />oriinrk.! rnd shr. tr*r Rldh3 !o hd,ld'naconrMrrtr 0,i h.Ebyauh,rt cprcs.rivcrofrhisCnt.dCountylo.nl(utEn E
<br />7/EQJ
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVlnsulation
<br />Roof Sheathino 7/dzt lhlZ)
<br />Shear Wall
<br />Framing
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL )411r >rr€Yr-
<br />Certilicate of Occupancv
<br />Notes, Remarks, Etc.
<br />BUILDING-{NSPECTOR RECORD
<br />H::,::TK*iW24-
<br />P.m.R re,,rr,, /-Ah e. A-*i*a
<br />T-Bar
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