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SITE.WORK DATE ID/SIG.COMMENTS
<br />IIOAKEIII:TAUU;NSd]IAN
<br />UETLABAIION
<br />I hcrchy rflirnrnldcr pcnrliy ol p$iury.trc oiihc roll,tr'ins d.clanri(,s
<br />Ihavcmnwill.uinriirrCcnifi.n!cofcon$nltoS.lf.lnsurelin{orkc^ compcn\!ri{nr- as pn,vidcdl'otbvSccrion.lTu)ofrhc
<br />Labor C.nc, frrhc p.rfoflnamc oflnc work r.r *hach rhc Idm hnsucd
<br />I hrvo rnd sill.ni (in sorkcr! comlrnsrri(r iNnrrrcc. !\ rcqutcd hyScrio lTrx)olrt l:S.rCodc.lbr rhc Pc'ofnxtt f
<br />rhcuorkiorwhi.hrhtpcrmiri\i*uL{.My*.ilcn.oD[cn\rii{n,i'FUr.ccrnicrlndPolicynxmhcrsc
<br />C"rr,"r, C-o ?1*^44 < J T' J'^s
<br />=- sE4$w co rq3 qlbsb
<br />-Elt
<br />t ccnifyrhar i',lh. pcrlorh.n.. ol rhc wort lor lhich rhk pcrnn is isrucd. I \hrll nor c.dov rnv,rGon in anv nrnmr
<br />$ sbb..om bicr ro rhc wortqs .onpdsari.n laus ofo,lifo,ni.. snd a8rcc thd ifl snouH }t..m subjd k' rh.
<br />workds ...rFnsalion lrovisions ofSertun l?O0 oflhc t tu Cqlc.l dtrll. fonh*irh comply airh rtx)r povhionr
<br />WARNINC: kihre h sccurc u.rkcrs' mn,p.n\nrion cov.'rgc it !trlasful rnd shnll subJer arr cmlnr)s ro rimin0l licnrlrt! ! l
<br />civil lincs !p (' on. hunded rhousrnd dolhr lsl{n.uxrr. in lddirn,n lo rhc.on ofcom,lcnslrion. dr fl8cs as Povnhd rtn rhc
<br />Sc.rtr{r.\l)76olrlr l]lxtr (i{!.. i .n\r rtrJ rrntr't! \ fcc\
<br />6lrll rt
<br />I h.rchy rlltr ufdc. |r(nJryoll)cUtrry rIxr I ]D,lic.tr{i\i,r1 ol Chrt,rcrc(.o nirncirg wirhSc.rhtr 7(xx)).1l)nisi(nr 1
<br />rr rh.ll',\i'r.\\ xn,l l,'ofcsi,trr ( (!lc. . nrvliccn\. '\ i',lrlLlor( rid cli..r
<br />q5g1.t3Bc3q
<br />,,,. 6tt)ln c6c.I *51^
<br />(l()NsTRtrcT!oN I FNITIN(i A(;8NCY
<br />I hcmby attnr undcr pcmlry of p.lury ln{ rhcrc t a .on{fl.ri kndirg 4emy for ihc lirL|Mnc! of rh. *.rk lor which rhn Frn is
<br />i\sxcd (Sc. 1097. Civ C L
<br />t nici\ Nrnt
<br />-
<br />lJn crr Addrcss:
<br />-
<br />APPLICANT DT(]I ARATI(TN
<br />I trEry amnn utrdcr pcrrlly ol Frjury oN oflhc rbllo*i.e d(larriionsl
<br />Dcm'lirion Ptnnf$Asbc(os Nolifica'ion Fcdcfu r Rcguhln,ns (Tirlt 4], Pdn6)
<br />_R.qutcd Lctrcr ol NdifEarion
<br />_t c.niiyrhrrrhc f crrlrc8uhridN rcsirding rsh.nosd,mulnc nol imlicrblc tu rhn pmjccr
<br />. ih l rl[ $ovc inrbrnEin,n h c.trNt I a3B ro coml'1UH*'*"*-*''':,:#Hr lrll s';rllrr;','rtll;r,ly wirh !ll(ir!r d coutrr!
<br />ryr Counryk,cnrn urx rlr
<br />nborr nE n,ncd po!.nv rd iN!..rion ru
<br />ApDli.onl or A|len( Sixnrlrft
<br />1 \JtC\5e1
<br />t/rtl tt
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Rool Sheathing A 'allK O1/v(P-I Fa-'-'
<br />Shear Wall
<br />Framinq
<br />lnsu lation/Enerqy
<br />Drywall
<br />Brown Coat
<br />l\4ason ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif.
<br />FINAL (tlblt lz (?l,ts>a- /n-
<br />Certificate ol Occupancv
<br />Notes, Remarks, Etc.
<br />*trxtz-, .pJa-rz - p)Dtlz-, bf r,* ann ? &ufrq / 6\
<br />BUILDING- INSPECTOR RECORD
<br />Ext./lnt. Lath
<br />OIVNER AUILDER DELCNf,ATION
<br />I hcrcby arr und.r Fnalry of lrcrjlry lhar I m cxcnlpt tinm lhc Co tudor Lii.n* L3s lor ih. rotlowire rnson rsr '7ol l s
<br />ausincs aft Profession Codc): Any Ciy or Counl, $hich rcqlncM l$mir to con(rucr' .kd. imptorc. dcmhh or Ep,n ,nv
<br />srru.ruc- rirr. ns hsuancc. rl$ r.iutcs rhc arplicn.r ror \u.h lErmit ro filc! sisn.d {srcnEnr rh0t h.or shc is li..n*d pusuanl
<br />ro rrE pmvtions ofrtr ConrEcror's Li.cncd Lrw (ClEplcr 9, Connn.minB unh Sc.rion 7tn0 or oivhion 3 orrlt Businc$ and
<br />Pmlc$ions Codc) o. rhtrl h. or shc G cx.mpl rh.rcti.o dnd rhc t{sn for lhe alLsc{.r.nprion Any vn orion.rscdhn?031.5l'van,
<br />apnlicam tG a p.mit subjeck lh€ atplic!.r k' ccivilpcnaltyofnor mrcibai nvc hundrcd dolhr (S5m)
<br />l. !s owmr ot lhc pop.ny. or my c,nFlo)cs virh w!s.s a\ rkn enc .omFenslr ion. will do fic atrk !d the nnfm ir mr
<br />inrerd or oflcftd ror ele ( Ss ?044, Busines rnd Prnrcsrnnrs Cdc Thc ConkMrors Li.cnse ljw docs not .prlv lo !n o*ncr or
<br />th. nmncny *h. triE. oi iniporcs rh.@n. sod qh) dds sRh M* hinselfor icr*lfor rhmuah hic or hcr own cmnlnv.cs-
<br />ln,vid.d lhlr such i,nprcvcnt.rs m d ifcndcd n oltu for uE It h(,wcw( lhc ttr iuing or imnmrcnEnt is sU sirhin oft ]er
<br />of co',{hrk ( rhc ovrcr Buildcr will lut rne hrd.n or pmvinS thd hc or sh. dn d bdU ot nl{mrc lhc Iftrdy f$ dr tNrlnc of
<br />I. as ovncr of I hc nmnenr. !n .r.lusivcly .onrrerirs uilh li.rn{d ..nr.doN ro consrtuci rh. t)mier (Sa 70{4. Brsimss
<br />a Pmr.rsi{ Cnd.: Thc Conlt0clr's Li.cns.l-Nw dfts nor lprlyro e.nsner oriii'Frlv who l,uildsor i'ntmvcs rhcteo!-
<br />dnd sho conrE kfor such Isrjc.r with t (1'nhclo( s) liccn*d poi\uamrorhcCo r0clorrl-ic.nsc ljw).
<br />-ta
<br />crcmprundcr sNl6.-. B. & P.C lin lhis rca$n
<br />D.rF _ O*n.r
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