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SITE-WORK DATE ID/SIG.COMMENTS OWNER BU!LDEI' DELCA&{TION
<br />I hcrcby a0nfl undcr lcnah, ofl,crjlrr rhar I!mcxcmrrl froh rhe Contact,N Liccnsc trw lnr lhc lollosins relv'n (Sdc 70:115
<br />Busincs rd Pnrlssnr C{4ld): Any Cily oi c.xtrry whi.h rcqurcs a Frnril ro onslrucr. slrcr- inDolc, dc'mlish or rcI[ir iny
<br />eru.turc. prkr ro ns tsuri.c, also rcqlircsrhc aplic r l'or such Frarit h iilc 0 sisndd {src'rud rhdr ttror (hc ic liccnscd lunuot
<br />t, rh. rovti(,F or t+,Conkn ttr\ Licetrscd ttrw (charr.r 9. connEncin8 wilh Scdion 7l{x) of Dirhion:r orrh. Bn(in.$ trnd
<br />Pmfcsions C.n.)-n-ih h.orshc n cxcm,,r thcrcfrom md rhcblsh forthcallcscdcicrlprion Anyliol,rionorSccliotrT0ll.5hysny
<br />ap!licanr aora pcrnrir sul,jects rhc appli.anr ro a.i!ilncnrlryolnor moBrhan nv. hundr.d dollur(3500).
<br />-1,
<br />ar owifi of rh. pioFdy. or nU c'nployr.{ wnh vrtcs al lh{t slc compcnsllion. *ill do rhc *ork dd rh. xrmrun h mt
<br />i cnlL\t ororlcred lor $lc (Sa 1044. alsi.cs lnd Prcfesions Cdc lhc Conractr's Li..n{ Lrw docs not qlt)ly ro !n owner of
<br />rhcpn,rcdy sho huilds or inpn*6 rlr6n, md who d6 s.h work hi:nselfo, hcr{lfor rhr.u8i hn ornerosn cnlloy..s,
<br />nnvidcd rhat su.h impmEmnhemi inr.ndcd ororleE'd lorsL lt hokki rlt ttuildinBor nrq trtnrnr is bH wirhin .m )rd
<br />or compLrion. rhr ow..r auitnr {ill harc llt burdcn of flotug rMt hc or st{ did nor hlild 6r nipow thc tmldy lnt rhc puqne of
<br />-1.asownqollMpopcny.amcxclusivclycontraclins*irhliccnsdcont
<br />.^ i{,..trsrfl.r rtr pmrt (Scc ?014. Bu$nc$
<br />{rn Pft,fN\ion Codr: Th. Conta.ror's Lrcns. t-rw dfts mr rttly i. anouncr olJ)loJlcny who huilds o. impRrtr lhcrL'on.
<br />.nd who .onrads for such rmjccrs *irh a Cont6cro(9 ltcnEd puBurrr b rhc co.h.roir Li.cns. b*).
<br />-l
<br />amcrcmo un.lcr Sarion- B &P.C ior rhis rc$oh
<br />D .: ()*n..
<br />]taatrElll:cau[ENlalll)N
<br />DECI,ANAIIQ!
<br />I hcrchyulr'irnundcr!cnalrtorPcturyo corthrrolk,tri'igJ..lrruriux
<br />-lhavc
<br />ald $illroitrhin! C$rifici.orCoiscnr b sclll'rsutu t,r workcs-.onrB-nsarion..r pnvidcd I{rbysccrn lT([ofrhc
<br />llhor Cdc. lor lhe lcrfomNc of rhc work fq shich rhc pcnnir il issu.d.
<br />I hnv. rnd w,llnrrinlrin work rs compcNalidr irsuEncc. rs rcquircd hyScclion.lT00ofrh. tjh.r Codc. for rhc Pcrlonuncc ol
<br />rhc work lin whi.h lhis p.rnrir is isscn. Mr workcr' €omfcn$l ion insuGncc cuic. md Ix,li.y nu $$ acl
<br />PolicyNumbcr Expncs
<br />-l
<br />ccniiylhrr nrlhc |crli,nnan.coflhc *ork lhr whi.hihis pcnnir h irsxcn,I slull nor cnrlloyony!c6on in anrmannor
<br />v, altJb..om srhld r. rhcs.rkcs.o rF,r..riotr l.Nsorcnhlornir. rDd rrrcc rh ift shrld hcco'ft subjc.r r.llE
<br />$ork.rs comncnslrio pn,!nn,N ofS.dn'n.17(XJ ofrhc lf,htr (iilc,l rhrll. nnhtrirh comply{irh rtx,{ Pm!i\n)ns.
<br />WARNING l; lurc Io surc sorkcr{ conDcn{ltion covcrag. r\ unhwfxl. ! d sh.ll sublett .rr cmplotcr ro oimimlFtuhi.\ rnd
<br />civil fitrcs u, lo onc hun'ircd lhouend dollu\ (Sl(x
<br />Scction 3(,76 oithc tjbo, Codc. inrc.csr r.d 0rk,Ny \
<br />.l comncnsnlion. damgcs !\ p(
<br />L'"1. 7-//-I {
<br />t)t.tct 1k,\fl(r\
<br />Ihcrcbyffinnudcrrcn.llyol0crjuryrh"rIamli.cnedundcrpn,eisionorChnlrd9(conmrncin8BirhSccrion70(n)orDivisn.l
<br />dr rhc ansin.s Md Phrcsions Codc. md my licctrsc is iD full hre $d c'Iccr
<br />7-tr-/8'
<br />CQNliIBIIJIQlIXNDlliCrlliDlCI
<br />I hcrby rlftm tRlcr lct.lryolr.rJuryrhal rhcrc h ! con\rn(li,)n leDding rgcnr, ft rhc rcrfuhn.tcc orrhc *orI lnr *hich rhi\ t--i,nir i\
<br />'s\ucd
<br />(Sc( loil?. Cir C.)
<br />AITUCAIIDECI.AEAIII}N
<br />I h.t]6y rrhn undf p.nalty of Frjury orc ol rhc follosine dchBr ions
<br />Dcnolirion Pfnirs Asb.sror Notficdion Ftdcr0l RcguhinxslTillc 40. Pan6)
<br />R.rtu ir(L lrnrrol Nor'lnniof
<br />I c.' iiry rhnr I lrrt rcad rhis q,fli.diotr nnd {drc rhd rhc rh'vc itrloflu bn i\ .omd L!rL{ b .o ysirhrLl ailyind Cotrnry
<br />o'ti'rtrcN r J Srnrc Lws rclrrirS rtrrlCotrtrlylo ctrrcr uJ,fn rlr.
<br />atDvc mnrnnBd pnncny ntr in\
<br />r\pDli(nnl or,\tenl SiInatuR 7-t t- r5.'
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsu lation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq
<br />lns u lation/En erq y
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Itrlasonry
<br />Pool Fence
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />FINAL .n )-:vCertificate of Occupancy
<br />Notes, Remarks, Etc.
<br />BUILDING- INSPECTOR RECORD
<br />klld.r's Add.s
<br />-
<br />_l ccnilyrh3r rhcied.rxlrcsrlnrions r.lddi'rs rstEdos rc r'vrl,rctrrrp icnblc to lhi\ px,i.cl
<br />Forms/Steel/Holdowns
<br />T-Bar
<br />x I /?/tx |Ss,
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