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GRAOING-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS Ow*FBoildd D t.Elion
<br />I hRby amm undd p.hlry of n qorythd I d.r.h fomrlE Co r*106 Licc* Lrw for ft. followiiS Mm. (6,70115 BNin6s
<br />lld Pmf..rkrn Codc): Aoy Cny or Couity whicn Equn6 . Fhn lo otrnMr. .ha, inFr!v.. d.mlLh o, cFt .ny {rttclo( Diir lo ils
<br />iiiu.nc.. ale Equics rh. applionr for sch F@ir ro tl. ! r,8..d 3rd@rr rbtlEo.$. ir lic.ed purs&t l. $. Dhvasiotr\ of ln.
<br />Co r!.roa* LirMd L.w (Clqr.r I, Co,lmEing *ilh Sdlk'o 7000 of Divtion 3 oIrtE BusiMi ard Pmf6tiom Cod.l or lhrt h..r
<br />lhc i.i ddfl lh.Efmm.d drb.!ii fo, tlE!ll.B.d a.ni$aon.Any viol.rio. ofS!.1io.701l-5 by.ny,irlid torip.m suhi*( rh.
<br />qDlicat ro 6 civil p@hy of bl mE rhln ,iv. hodrcd doltd (t500).
<br />-1.
<br />s owr of th. Dmp.ny, or ny .mplorG wnh Mt s .3 rh.ir r.k mnp.trsrhr will do rh. m,lr ard th. .ttucluc ir mr in'dd.d
<br />or o6.rcd for $lc ( S<.?04{, BusiBs .nd Pof.sdon! Cod.: Th. Conl6crol, LicN Law dod mr Elply to e ower ot rh. pmFny
<br />who btild! or impmv.i thd6r\ r.d wh. do6 tuh mrk hi6!.lfor h.Rlfor rhreu8h hi. or ls own cmphyc, 0rotid.d lhll ech
<br />inprdreDll !E mr int nd.d or olI.cd lo. sL. Il. t w.B. dE hlildinS or impbEmnr Le hld *nhin oG ]ar of cotrpl.lh( tlr
<br />OvmFBuildd will hav. rl! t{rd6 ofDbvins rhlt h. or 3h. mt blild or impow t r rh. pnqbF of sl.)
<br />-1,
<br />ar owr of rlr nrcF.ny, !m qcluriEly .o.rdi.8 wilh li..trt d co.rEroB |o effirud rh. t'6j.d ( SB. 7044. BEi6s and
<br />tmf.sion Cod.: Th. Conlr..lor's Liens t v dm ml .pply to .n orm of propnly wtn buildr or ihptom lhcrcn . n qtn
<br />conraclc for scfi pmjclu wirh d co.rrrcro(, lie.*d puli@r to dr conreroci Lic.G liw. ).
<br />I d dcDpt undr S6rion
<br />-8.
<br />& P.C. for thi.r @n.
<br />loarDSs-cqi4tlltAllo!-ug.aaaroN
<br />I h.Eby .mm und.r t mlry of 0.du.y orc oflhc followin8 dccla6laoB
<br />_.1 h.v. and will miniain r C.rlificI. .l CotrEnt lo s.lf-l trruc lo. mrl.6 .onFE$t ion .3 tmvid.d lor by Set ion 3?00 oi lh.
<br />Lahorfod.,lor rh. ll.rfodaN. olrh. worl l"r*hrh lh.Frmrt n 's.d
<br />f hr'. r.d w,ll m,,ir.,i "6d<6' @nn Nr 6n inMrq d Equitd lry sdio. l70O ot fi. Lrlior Codc, R'r rh. ,E aom.c. oaih.
<br />work for which rbt p.mn t biu.d My Mrtd conp.ndion ins6c. ceid .rd ,olicy nodb.r dcl
<br />cdid: .* Nld (*nnr>
<br />p.ri"y r,.t-. ir V.zz?c fr o aZ. (4 e"ri,.,
<br />CThis kt ion Rd mr b. Elpldd il rh. p.frr ir for o,E hLndEd dolLE lt,00l or Ls)
<br />/b /", ),/r/
<br />I c.dify rhat in rh. p.rformncc of th. *o.k for whicfi rhis Fcrmn ii hw.d, I shrll mr cnDloyany ncMn,n dnymlnn.r so ae ro
<br />hc.m. $bj{t b th. w6rk.R onIEn$ri,n hq. bfclla ard alB ihar il I .hould b..om .ubjd to (h. worlcrs
<br />ll, forrhwiti.oqrlywirh rho* lovi.ionr .@nD.n dion pmvirioB afseion 1700 ofrlE
<br />,^,- 2/2, ll{
<br />,"n**n"T'*7**I*@r@s. h uota*tuI. o.d !h.ll $t'jer lo)€r lo cnmiMl p.nalli*andcivil
<br />fincs up to on. hundr.d thou.afld dollotr ($100,000),in lddition lo rhc cosr otcompcn$tion. d.mg6 at rovidcd lorrh. S(rion 10?6 of
<br />rh. Ljho, Cod., inr.d' ,.d anoftr'3 fes.
<br />LICENSED CON'I'RACTOR.S DECLARATION
<br />I hcEbyamrm !nd.r p.nehyofnsjlry lh.t I m lic.n*d und.. !'mrqon o[Chnptn o(shNrcrns wrlh Sdnn 7000) olDivirkin ] ol
<br />rh. Bur'*$rnd Pmrdrr,ni C.d., snd mj I'c.nc h
<br />'n tullf.rc.ud.ht(l'
<br />?ZZZ44.'2
<br />(.().lSll.LCltlllINl2lli(irlliiil(I
<br />I hcEby dfiim undd prMlly ofFjua/ ln,t th* n . .on.trudion l.nding sg.my for lh. p.dormncc of th. work hr whicb U!i! Nrnir i
<br />isocd(&c. 1097,cir c.).
<br />A.ttrtc lliiDlel BAl!.oN
<br />D.tr$l FnPcnnrlslsh.srnsNoriicirionl;.d.r.l R.lulirion(l[1.40, Pin6)
<br />Rcqor.d Lcll.r.lNorrlicarion
<br />_lc.nilythar thc Ld.El ..rubt iof,s E8rdio3 db.,to! r.mwl oE mr rnplicahlcro thh pmJ..r.
<br />I ..niry dEl I hrv. Ead rhi! appli€rio. and lrat rh.r $c rb6v. i.ftmri.n i. ..rd. I .8r.. lo 6mply wnh .ll Cily od Colnty
<br />ordiMm* 6nd Srd. llB El.ring robuildin8 orirruciioa rnd lmby.urtbrir El'l*nrlriE otlhh Cny snd Cou yro ot.r ltbn rh.
<br />Preliminary Soil Report
<br />Excavation
<br />Fills
<br />Sub Drains
<br />Buttresses
<br />Soils/Geology Report
<br />Statement of Compaction
<br />Compaction Report
<br />Flood Elevation Cert.
<br />Paving
<br />Sub Grade
<br />Aggregate Base
<br />Water Test & Seal Coat
<br />Asphalt Concrete
<br />Soils Eng, Cert
<br />Rough Grading Reldasb't
<br />Final Civil Cert.
<br />l-
<br />FINAL 4V ru.ttr./ru^+
<br />Notes, Remarks,Ei T
<br />(
<br />+'l-tr-5
<br />ahov. m.n'i.r.d Dmn ny fniin$(rion nlJa.*-"^,;.":,"".,^;:::;Z';' 24<,-'- ..,. '-,/ 3, f rtr.
<br />.,,^,,,*"*,,,,^d -a-Ern,-h -Ttrh-,'t -
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