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SITE.WORK DATE ID/SIG.COMMENTS OmBuildc Dclrraim
<br />I hcrby rfilrm undor poulty of pcrjrry thrt I m :rmp fmr thc Colttnctar' Llccot. lil for tho follon ln3 rclcn (rcc.703l.t Buriacrr
<br />rad lmforim Codc): Any Clty a County ?hici F$rln, r pdrlit io cortrrr, dr.', imFovc dmolirh o. rpdr Ji, tructwr, pdo. to ilr'
<br />lmrtrcq dro ltqul.!. tt rpplic8t f6 ruct Frtlh b ,lh r tlgrd illaar.nt fi.t h. o. rlr. fu llcausd po,lulrlt lo lho Fovirioil of tht,
<br />CooErclor'r Llcard Ll, (Ctqtcg, Cotllnadl3 d$ S.clo[ 7000 of Dlvidoo I oltho Bu:inor md Profcrdor Codc) or th$ hc 6
<br />rhc it qmts thdlt!.n Dd ih. b.da fcih. dl.fd a6trl6 J\ny vloldo of Scdo 7031.5 b, sy +plicui fc. p.nnit tubi.ctt ttr
<br />.p,plisr !o . clvll p.rdry of rq nqr urn tlrr hudrd dollu (1100), ,
<br />_1, l mci of orc popary, a ny enplryrcl 116 rttrr u rtdr rob comFuaiql w{ll do lhc ?ott rod lh3 ttruclutt b [ot lntodcd
<br />c ofrcad fc [lc ( Scs.?o,l.l, Dutlo!., nd hofrrlou Codc Th! Crotllalor', Llceus Lfi do.r rd rpply !o u ourr of thc prcpcrry
<br />rho boildr 6 lmFlE thoqL d xho do!. rrli rqt tiltnxlf 6 ta.lf a thuth hl, or hc m mployq, trcvid.d th{ ruch
<br />inprcynnao E not lnraod.d a off.?ad fir da 14 horctEr, 6a luildtn3 or inprovmt h rold within oc ycr of complction' tio
<br />Orna-Bulldc vill lrrw thr lurdo of povlnj lh{ hr a rha ror bdld 6 lmp.or ffi $. purporc o( [lc),
<br />_1, u omr of tlrc ,r!,p!fty. m uclulnly orrcrlaj wfth tlmrd 6trta to c.ndruct th. Fojcct ( Sc. 70a4, Euinq ud
<br />Prcfoim Codc ?ho Coot]l6{or'r Ucaruo Lrr doat rlo( agply !o m o*fir of p.opaly rho buildr or lmpovGr thfioo I ]ld iho
<br />corfidr fc tuclt Fljcar witi r Cortrto(r) llaa&d plrslsrt lo lhe Cglf.crorrt LicorG L.w.).
<br />lrncr.milundcs.crion .1, ap.C fcOtrrron.
<br />Ddq Omc
<br />@
<br />I hcrcby dllnn ua&rpadty of pcjury or of tho follodn3 &clntiau:
<br />_lhewmdwillmrimdnrCcrrlllcrrcofcooraltoSclf.lnrutrfavoittil'cooDqrrtlil,s prcvid.df6byS.€dn!700ofrh.
<br />Lrbc Codc, for0rc FrfcrnHco of thcrct fcrhich tho Frnit l. irucd.
<br />_[ havc urd will mrintrin wfikefl' compomtion ituurmcc, lt
<br />wtrk for which thir pcrmit h irued My rorkm' compcnrrtion
<br />rcquird by Soctlor3700 of the L$or Code, for thc perfonnrnco of thc
<br />huutrnca crticr rnd policy numh rrc:
<br />(Thir roction not bo cotnplstd or lcsr)
<br />for which thir ir irrucd, I rhrll nc uly in rny mrnn6lo tl to
<br />thrt if I rhould to the workcn'
<br />provirioor of Soctim 3700 of thc bbc I
<br />WARNING: Frilurc to rGsurc workcfl'
<br />fino up to onc hundrcd thoruurd &llrn
<br />conrPclltrtion
<br />(S100,000),in
<br />covensc ir untrwful, urd
<br />rddition to thc cott of
<br />thc Lrbor Codq intdcrt rnd rttqr3y'r fr!l.
<br />LICI NSM CONTRAETORS i|ECLAR TION
<br />I hcby rflim urdG Frlty of Frrry Urd I .rlr licot€d utda prcvirlo of Ctqr6 9 (cmmmcinS vith S(rim 7000) of Dlvirio ! of
<br />the Businerr rnd Profcsrionr Codo, urd my licenrc ir ln full forcc rnd cffcct
<br />l.\//6Llccnro
<br />o
<br />of pcrjury that thcrc ir r conrtruction l8sncy thc of thc work for which thir pcrmir ir
<br />Lcnder'r Addrar:
<br />APpr rc^rYT's DEcr ^BA"rIoNDcmolition Pemir-Arbcrtor Notiflcrtion Pcdorrl Rcaulrtionr (Title 40, Prrt 6)
<br />_ Requircd Letter of Notificrtio,n
<br />_I certiff that the fedcml Nbcrtor lre not rpplicrblc to thit project.
<br />hrve rcrd thir k sorrcct. I rgrrc to comply wlth rll City rnd Counry
<br />rbovo nmtioncd proporty
<br />Applicurt or
<br />Perminec ntme (print):
<br />urd rutc thrt
<br />urd of thir City rnd County to Gntcr upon thc
<br />Set Backs /
<br />Forms/Steel/Holdowns 7p7E \
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />S u bfloorA/e nUl ns u lation
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Requlrements
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certificate
<br />FINAL -t2ll .UU ,ile/n=- Zl
<br />Certiflcate of Occu
<br />Notes,frY€'-)e-/
<br />..)
<br />a 7
<br />,,-rr- 1.,t O C),r.;Lt ]4 1tr4 -Stf U 4.a-Tt.-{
<br />v -1
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<br />l,{
<br />L{.V'I,q,,ry
<br />BUILDING- INSPECTOR RECORD
<br />I')a.,. ,l 'r(\ A,
<br />thrt
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