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SITE-WORK DATE ID/SIG.COMMENTS oWNER B(rlLDliR DI,ILC R,{'l lON
<br />I hdrcny rfinr uid.r pctr y(n Frjury rhrt I m cr.n{, li.n rh. CotrrBcr,F l,iccn\c Ir* fn rhc folb*ir8 lcaq)n lsc.70315
<br />ausircls inl Piof.si$ Codcl: Any Ciry or Counly which rcquircs tr p.nnir io .on{d.r. rlr&, i rmvc, dcnxtlth , r rqrin
<br />'nyslfl.turc. prhr nr irs issurn.e. rko reqrircs rhcapplicrnr f{tr \uchtcnnir ro filcr si8ncd (tIcnrcnr lhd hcordt n li.cnscd Nmu r
<br />h IItr pn,vi\ir s of lhc ci)nlracktr s Liccnsed Lrw (Ctuplc. 9. C.mnEnci',9 *irh Sc.riM 7lX)O ol Dirhion 3 of rh. Bd\in.\\ a d
<br />Irolissi()n\Codc)orrhrrhcor\hcircrcn lhcrcf(nn.nd rh. hisis nrrhc.llcg.dcrcmprbn Aoyvt trn,nofSccrtun 7011.5 byany
<br />amlic.f for n p$nrn subjcclsthc lpflicanrr,) rcivilI)cnalryol nor nnrc rhd fiv. hundrcd dollr$ rSsLx])
<br />-1.
<br />!s oencr ofrhe lls,lcny,,tr nry cmpbyccs wirh wdgcsasrhcir vncconlEn\rlion. willdo rh. surk lnl rhc trturc h n.l
<br />i.rcndcd o'ofic(d fir kk (Sd.7(l14. Busircs d Pdtssiotrs Codc Th. G)nruttr\ t-i.cn$ Irw dEs trol lPplylo morm, of
<br />Ihc Fnpcny who ttrild\ or impmKs rhcEn. rxl *lil dmskh $oA hnnsclfor hcr*lf.r rhmugi nis or h.r o*n e,npl,,yc.s,
<br />lmvidcd rlut such imprcrnE$ m nor inrcfdcd or on'ccd f{r elc ll k,wdtr. rhr tnrikling .i inltl$vc rd n sH sirhn, om Ftr
<br />oico.Dlcriotr. rhc OqDcr Suids uillhaE rhc turdcn ol prori,rg rhd hc or shc did nor huild.r imnrcvc thc lnPdy for rh. !!'ID{ of
<br />L rsoqncrorrhcflop.ny. amciclusivclycotrrrcritrs wirh li.cn\c{l rotud.n,s ro.onnrud llt In.,F.r lscc 70,14. Bu\i"r\\
<br />a'xl h ixsfi Cnlc: 'rhc Conts.kr's Li..rr Ijs docs Dor rt)Fly nr !o ours ot pror.ny { ho huilds or inpnrts tltrcotr.
<br />rnd who conlmclsnn such lroJcct wirh r Contn b(,Ii.cns.d Nrsunnr t)rhc (bntrcktr s Liccnsc lrw)
<br />-l
<br />rcxcmlr undcr S.cri()n , B & P C l.r rhis rc nn,
<br />Dlle -
<br />()rn.r:
<br />woRKEiai colril'Ns rt()N
<br />DI,CIIAAIIA!
<br />I hcrch,dlnn,undcrr.fukyof,cjuryon olrhcldloqingd$lnarionsl
<br />lM\c nl*illnuinrainr Ccnirl.rrc ofCon\cnr ki Sclf-lNtrrcfor wor[c6 cnmncn\atnn,. a\ F)vidcd lorhySstiotr.]?lx)olrhc
<br />l:tn, Codc.li,r rhc lcrlonro(c ofrhc work lnr whi.h rhc lcnnx i\ rs{r.d
<br />lhrv.rftl*illnrinrrintrorkcri.onll)nsalio.nNulrncc-a\rcqutcdhyS..rt,nlTtx)orlhcLahorCodc.rorrhcpctr.niu,f,cof
<br />rhc work r.r whi.hrhis pcflnil is (wl. My worker' smncn\al ion inulMcccrnicr rtrxl ,tli.y nun$.r uc:
<br />Polry \umbc-
<br />-ttfim(
<br />-lccdiiyth(rirrhc,'trli,rnBncpofrh.sorkforwhi.hrhn!.rrnir
<br />i{ i(suci.I\hnllnol ctrDlo,rnylcho ntanyntrtrncr
<br />$ r{t,ln. r srbj..rh rhc wo.[LrC conDcns ior hw\ ol Cllilbnrirl nd agrct rhrr ifI\hould lx.orrc s'ht.lr{'rlt
<br />rorkcs'cotrf.n\arionpmvhion\.fSdn,n:]?00oflhcLrtxrCodc.l\hnll.loiihrirh.onrdy+ilhri.{rn'viridr
<br />WARNINC: fJihrc n, *crt trorkcB'co lrns ion cowri8c rs u!h*ltl. rnd rhall srhjet an cmplotct r. qinrinrl n€nahi.\ rnd
<br />ciril fincs u! r' onc liui rcd rh.urdnd d.lli$ (Sl(D.ou))
<br />S.cri.n.1076 olrhc Lrhn Cod.. iNfic( Md droirry \ llcs
<br />iri(r n, drc rod of..trrpcrs ion. drnn8$ as polidcd for rhc
<br />I hcrby,mmr undft t'.trrliyofpcrjury th0t I {m licctrr{ utrdc, pn,vki{'n.rChtrflcr 9 (conrmncilr8 {irh Secrtn ?(n0) orDivisnn l
<br />or rhc Bx\incss,nd Ptur.\si.rN Codc. iDd mylicctr* n in lull forcca c(sr
<br />L
<br />CANIiIAIJ!]IIONI.INDIICIIiINCT
<br />I hcrcb, nLtrn u cr[EnohyofNrjuryrhd hcrcisd.ondocri(,nkidinSaecmyforrhcterlhrnumcofrhcworkforwhichrhirlctmilis
<br />issucd (S . :1097, Civ. C.)
<br />ATIUCAII-DEIIdBAI]ON
<br />Ihdrr'yrfllmund$ p.nolry of pcrjury orc.frhc arlk,wins dElIarion\:
<br />Dcoblirion P.rnirs Asbcsos Norificariotr l'cdcal Rc8u,aliotrs (Tillc40. Pan6)
<br />-Rcquncd
<br />L.Ier of Norili.albn
<br />I r ilyrh r rhc,e'lcril rcarhli,)m rgrnling r\h.sos r.ntr)hl rr. tror.mli.ihlclo rIi1!(,1..1
<br />-l
<br />crnil!rhrr Itutr!r.r rhaatrliMltrri il$rcrhdrhc h,\c irn{nuri,r i\.omcr lr3rNr,.onDlyrirhrllCiryrndCount!
<br />o'(li',rn..\nndSrrrr l- tr\rolnr' sk,huinlirg(.n{rtr.ri,r. rlhcrchyr rclr.\cnrrrivc\olrhi\ c[! rtrd co
<br />nholr Nnriorcd pmpcny tur insF{rion
<br />Appliunl or AEenl SigNture:
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Roof Sheathinq 7/<(lx >\GY
<br />Shear Wall
<br />Framino
<br />lnsulation/Energy
<br />Drywall
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certil.
<br />FINAL 6/trl u 50<1
<br />Certilicate of Occupancy
<br />Notes, Remarks, Etc.
<br />BUILDING- INSPECTOR HECORD
<br />UFER Ground
<br />Subf loor/Vent/l nsulalion
<br />Ext./lnt. Lath
<br />knd.a\ Addmr.
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