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SITE-WORK DATE IDiSIG.COMMENTS OWNER AUTLDER DELCARAT'ION
<br />I h.Eby amrm undcr pcn.lly of pcrJxty rhar I t,n.rcmp( noln rhc G)nhlcror' Lrctrs hw rbr Ihe following rcr$n (S( 70-rl 5
<br />Busi.css nlld Proic$ion C,xld) Any Cily or Counly shich rc+t.s , ,.rnril ro con(nrr- llrcr, i'nprovc. dcmnnh nr Rnrn rnv
<br />srrucrurc, prixt' ils irsuancc. also rcquncs lhe llplicd lnr \u.h lcn l lo filc ! sisftd {xrc rtrr lhol heor shd i! li.cn*d pusurtrl
<br />ro rhc Frvisions oflhc Conrlrck \ Li..nscd L.s lcnnlrer 9. CoanEi.nrg wnh Sc.rion T(I or oivisi.n I ol lhc ausincrs o.d
<br />Pmfcssions Coder or rhar lt ui shc ir crcinpt thcrclii,m and rhr l,n\h for rhc nllc8cd cicrq,rbn ny vio[lionoiSc.rbnT0]1.5 by 8Dv
<br />,tpli.anr ror n p.rn slbjalsrh. lppli.,n o r.ivilpcMlllolnol nFrcrtm fivc hundtcd doll{rs(55(X))
<br />-l-
<br />us owNr or rhc poocny. or my cnrployer Nirh wr!c\ as tn.n sb conroln\ai ion. will do lll *uk ard rht ih-rm k no'
<br />imcMcd or onircd for slc (Sa 7044. Businc$ rnd P$fcssions Codc Thc Cdntdols Licensc Lle d.cs nol $flvlo m ow.cr.r
<br />rhc pnpcrly *h.6uilG or irqrov.s rtrmn. ond wlx' lkEs \uch *o* hnnscll.r hcrslfor rhn,ush hh orhcrown cnrPhyccs
<br />I)rcvidcrl rhnr su.h impmvc'mnk m nor irtrcndcn or offmd lor elc tt, h,*ehr, rhc burld,.3 or ilr{mEmni is $Il lnhin ore ,t
<br />or.onpLri,r. rhc Owrcr Buildq wiu hrk th burdcn ol Pmvirs lhd lE or sie dil mr boild or i.nlmE rhe F,Fn, ror th. Nqns or
<br />l. $ ownf or rhc ropcn). o exclu\ilely.orddingwirh,iccnrdconlract,Ero.onslruclrhclro.iccr(se7ol4Bu\inc*
<br />and F\oltssion Codc theContlcrols Liccnsc Lrw does nol lpllyk, rnowncrolproFny*h() huilds or iDlov.\ rhcr$n.
<br />rtra eho (o
<br />'rcr! tur nrh tn!t.d\Nirhx (ini'x.r licctrsd plrunr k, rh. Cotu0clor's l-iucns bw).
<br />I n rr\rnrl{ trrLl.. S.rr
<br />> /- ./.,,1 ,/ /d
<br />II[!:LA.BIIIQ!
<br />Ihcrcbyr{hrnu cr Nnrlryolp.rjuryoncurrltlolltrvirAdecl$rriu'\:
<br />-lh.vcorxlsillnuinr,insC.nitirrcofConscnrloSclat!\ueI
<br />workcn conDcnsarion.ds ovidcd lbr hr Smi ion lTm of rhc
<br />tjh, C.dc, for rhc ,slbnrumc ol rhc wotk for whah rhc ,cnn h nsunl
<br />I hrvc 0trd willminlain u.rkcrs .on[.trsorio. insurancc- o\ requncd hySNrion.]7(X)ofrh. tjborCodc.lbrrhc !.rlonnim' nr
<br />rhc wolk li) which lhis pernir is issucd. My worken dnnilcns"r id) i'*unmc caricr ud Policy nrn$cr m:
<br />l.cnii.v rhrl irrh. pcrh)i,Mn.c ofrhc wor[ Ior *hich rhis pcrmir 1\ is{rci.l \hrllnur.nrlnoyrnv Pcn.n in trny iuncr
<br />$ r\ k) hccom suhjc.r h rhc $.rkcn compcnsdn Lss .l Cililhr trir, xml ll8ruc Ih il I shou[l tlromc srhj$r h llE
<br />workcr\ .omNtrsdion provnini\ oI S..lion -l70O ol r1r Llt r I \hr l. tunhwiih cotr,!ly wirh rlhtprovisior
<br />WARNINCT Frilurc ro surc qlficr\ co rpctrs n r ! trrh$h,1. r rl \lL'll {,bE.r r, .qno}ar t, .'ntrr'l Ntrxlti.\ rrl
<br />.'vil inrr{ trp l. onc hundrc rhou\rid dollti (Sl(x).(xx)ro rhc ..( of.oarFtr\3ro . dr n!c\ r\ pn,v,d.d t, rlt
<br />Scc!.tr lr)76 I thc Lltxr C, c. nn.rc{alrddonr v\
<br />loV-)/:18 6
<br />I hcEby oinmlndcr p.mlty of ncljDry Ihar l,n liei*t xndcr pruvtion olChstrd 9 r.o'nnf,rciry Nirh SccrDn ?O0O) orDilkion l
<br />of Ihc Busnf,ss !u1 Pdfcssions Codc. ond my liccn\c n in fxll fotcc and cfltcr
<br />A.EBLICANLDECIABAIIO!
<br />I txd,y rfon und.r F.ahy oI FrJury orc orrhc folluwinS dcclamrion\:
<br />Dcnnlirn,n Pcrmirs Asb.skx Nolinc(ion FcdcolRcsuhbns (Tillc 40. Prd6)
<br />_Rcquircd lxtrfi of Nolifi calion
<br />I ccnilylhll th. ltd.rsl rcsulari.ns rcSddins oshcd.s remral rc nor {r,tltlbk b Ihi\ lt,jttr
<br />_l ccnilyrhrr lhrvc tord rhisi i.n d nrrr rl rrlrirJrc irlirrurnD is.oft.r t rErccr,.otrlPltsirhnllCiryrnd Coun{y
<br />ordinrnccs rtrd Srrrc Irw\ tl,trr8 t lnd hcrcl'yrullrri.er.pt scDrtrircsof rhhCn,and Cou.lylocnrcrrFnrrr
<br />rlFlc Nnri, l)loncny{q in
<br />,^."-e2-:3r:y'5.\p0lir! r !,r,\tcnl Signrr
<br />Za 5 6.,ra; c
<br />Set Backs
<br />Formsi Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/Vent/l nsu lation
<br />Roof Sheathing
<br />Framinq
<br />lnsu lation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certif .
<br />FINAL <S/at q f/aL4n (l- lot
<br />Certilicate ol Occu n I
<br />Notes, Remarks, Etc
<br />BUILDING. INSPECTOR RECORD
<br />"y
<br />-24
<br />COISIAIT:UANI|,NDINqICTNCI
<br />I lE(by amrm undcr Fnall,otpcrjurylbd rhd. is. on(ruclion lcndinS ds.ncy lor lhc Psfo'nu.cc olthc {olk fot which rht lcrnr n
<br />hsoed (se. 11197. civ. c.)
<br />L.ndd . NJ'tr
<br />t nd.i\ Addrc{
<br />Shear Wall
<br />Brown Coat
<br />,l
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