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SITE.WORK DATE ID/SIG.COMMENTS OWNER BUILDER DIJI,CARATIoN
<br />I h.rchy ail n undcr,)c.0lr, ol nc.luty rhd I dn cxcm0 fmrn rhc Cbnrmdos' l-i.ene Llw ior rhc following rca$n (s.c 7011.5
<br />Btr\incs\ and Eoics\btr Codc): An, Ciry or Counry $hich rcquirc\ a Fmrir t .on{ru.r, alr.t. inprorc. dc,relish or rcndt ony
<br />strucrurc. prior ro ns issuaRc. als rcAuncs Ihc rptlicnnr ror such pcrinir lo lllc & siSncd ( enf,nl lhot heor shc h liccn*d pu^ulnl
<br />b rh. Frvi\ion\.1 itE Conrad.r's Li.cn*d lis (Chuptcr o. Coatnr.cing *irh Sccrion ?UD of Division I ofrhc Burnrs and
<br />PmtsbnsCodc)orlh,rh.orshciscxcrttrhocrio,nn&lrhchtrsi\rorrhcalrcg.dcxciryti.n. tryviol.lionofScclhnT0.ll5byany
<br />apllicont ior i pcrflit suhj(Isrhc {plicant lo acivilpcnlltyoinor mrclhan fivc hundrcd dollam (5500)
<br />L {s owmrofrhc l,otEny. or ry.nr|lorccs *nh ErScs rs rhcir {rh ompcnsriofl. wi]ldo lh. *( andlhc\'dfl@i\ ,
<br />i' cfrlql or oflcrcd ror sk (56 ?044- Bu\i'rcs anr l,rolcrsions Codc:-ric C{,nracbis Lic.n\d h* docs nor amly ro an ownq ol
<br />rhc Dmrcny w,D burlds or in{,rcv$ rncNn- u{l wn. des u--.h work himscllor hcnclfor rhmuah his or hcr owncrnplorccs.
<br />l(,lidcd rhrr \uch impn,ktunh m nor intnLd oroflc l f(tr sL. Il h)$tEr. rhc bui[r8 or impre( rnl h sU *irhin onc J@
<br />olconlplctiotr,lhc owncr Buikcr vill harc thc ttrrdcn ol poving rhd rE or snc did mt huild or in{rurc lhc I^ psly for tu pufltor
<br />L x\o*ncr o, rlt pmpcnt, a'ncxch\ivclyconkk!ing sirh li.cn\cd c.tu&kr\ k,.onirucr rlt fn,jcd (Ss. 7Or4. Buqnds
<br />rnd r"nfssiotrCodc:1hcConlraclolsl-icenscl,awdocrnorlt)nlylo!no$ncroipropcnywhobrildsori pi.vcsrhctcof.
<br />rnd *ho contu 6 t tr such ttujc.rs wirh r Cunk!&trl s) li(n\cd luisunnr tu rhc Cbnt.ckr's l-icns L.w )
<br />I rir.r.n,0r utr'Ir S..ritnr
<br />lr'lr (r*n.r
<br />w( )kK IilLs' c(,tu PrNa,\ l IaN
<br />DIICLT!-BAIIAIi
<br />I hcrrh!rllntrrtrtrl.rI[trrLryrltr jrtrlo colr[cn)l],)si',A1.(r. rrnx:
<br />I havc ml will nDn iir r Ccdificdc of Conscnr fu scll- Iisurc for workcN omlEnstion. $ rhvidcd tu by secrn,n l70o ol rhc
<br />bbr C.dc. for rh. p.rfortunrc. oirhc qof* Idwhi.h rh. p.'nir is nsu.d.
<br />Ihrv.andsillman rin workcrr compcn\dn,n in\rrrn.c. rs nquncd btSc.rnnr lTUrofrhclii^r G e.li)trhcp.rn)nuD.c.l
<br />ih. work lu whicl rhn p.nnir is (rucd Mysork.^ .. rp.nsrrnD i'run r.c ciri.r Dd policy trunrhcr rE
<br />Policv Nr $.r: Expn s
<br />-l
<br />ccnilylhll in rhc |ErlbrnErccolthc w.rk tor whk[rhn Flnir k i\su.t.l shrll bor c Dloyrny!.6on in rtrymlnmr
<br />$ 0s b tr.om suhjc.r ro rh. workcH .onlrc.sarion hws or Cnlirornr., a aaG lhalifI sh,ukl bccom subjcd lorh.
<br />workcrJ onlp.nsdion prorhions of s(liotr 3700 ol rh. L$or Cod.. I nElL lonhsilh conpl, Nirh lho* pn,vtn,ns.
<br />WARNINC Iailurc lo scurc *orkcn'confensalion colemsc is utrhwtxl. a.d sh,ll sxbjLrr an.nploy$ lo riminrl |.ulics und
<br />.ivil fincs up lo ore hundrcd rhous.d dolh6 (S,00-Om). in addilion ro rhc con of .o'hpcn\arn,n. d,mAcs as Pmvidcd lor rh.
<br />Sdioo 3076oflnc Lohor Codc. intcrcn lnd ktrrcysfccs.
<br />Dd", 7 L9.13 noon*^'y( liaz"-aal ltit\sEn coNfR eToR
<br />DECI,AB{IION
<br />I hcrcby dnrm undcr p.natryollcrjury tlsl I !m li.cna'd undcr Eovisio. otCh.!lc! 9 (conrmmils sirh SNrbn TdI)) orDivhion l
<br />oi rhc a!si.c$ a d Eofcsk,n\ Codc. dd nryli..ns i\ in lull fotuc,rl cff..r.
<br />?:4= r A €.-r'z tt '
<br />COXSIf,IJCIIONIENDINGACENII
<br />I hcEhy !m!n nnd( p€nslry of Frjurr rh thc.. n a co.iru.ri.n lcnding r8.rcy ror lhc pcrformncc ot thc work forehi.hrht Fhnn n
<br />hlucd (Scc.3C9?. Civ C.).
<br />AIILIIANLD&;LABAI,U]!
<br />I lrnhy liinn un,icr pcnuliy orpcrlry.n. orthd rolhwins dc.hmrions:
<br />t)cmolirnro Pcrmirs^slEsros Norilicarion Fcdenl Resuhriotr\ (Tirlc 40. Pd6)
<br />-Rcqutcd
<br />txrrs ol Nor ifi.arhn
<br />Ic.dilyrhrrrtuIcdcrrlrc!ulario\nSrJnU^h.no\rrn)vnlnr.dorrD,,li.al,l(hrhnlrftr.{r
<br />-l
<br />ccnilithd I hnlr rcod lhhapllic ion and srorc rhar rhc rlnlc inlbrmrrn,n n corccr I asft ro .onply wirh lll Cir y rtrd Counry
<br />ordinamcs anrl Sl.rc L.ws rclarins ro buildins connrudion. rid hcrctyourhnnc r.trscddivcs orrhk ciry ond Countylo enrcr ullon lh.
<br />./
<br />Cha-vae-
<br />.(-1-tb
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf looriVent/l nsulation ,
<br />Roof Sheathinq -z/th4 -q)
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />fr/asonry
<br />Pool Fence
<br />Handicap Req-
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certit.
<br />t\
<br />FINAL v/1//4 .l 514 t,\
<br />Certif icate of Occu anc
<br />Notes, Remarks, Etc.
<br />BUILDING- INSPECTOR RECOHD
<br />(-rric'
<br />L/ndo . Adrtcs
<br />i,i#,^"l,il*"|.,x?,r<
<br />Pcm,i,mmme,Drin,, Ue{lot A-
<br />a
<br />T-Bar
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