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SITE-WORK DATE ID/SIG.COMMENTS OWNFJR B('II-DI]R DELCARATION
<br />I hcrchy iflnn lndcl,Mrhy oi pcriury rhar I m cxcmfl nonr lhc Conkr.t,N- t-icctr* liw lbr rhd nnlosirg ret{nr rscc 70rl.5
<br />Brsi'lcss rtrd P,oicssi,'n Codc) ny Cny tr Coumy iric[ rcquncs a Fnnil lo con{drr. t'lrcr' imDrovc. dcnd$h ot rcntir rnv
<br />slrxclurc. Nu l,) ns i\suai.c. aho rcquiE\ lhc lP,rli.rnr ror su.h Fnnir ro iilc r \i8nc'l r.rcmnr rhlr h.oi shc h liccn\'d Pur{onr
<br />ro rhc J,rovi\n \ .flhc Conlrrcror'\ l-iccn*l L0w (ChaPtct 9- Co.,nrcn.in8 wilh Sccri.i ?OD ol Divhion I ol rh' B!\nrss rnd
<br />P rcs$.nr codc) or Ihrl tE or\h. is cxctrl lhcrclio andrhchasi r(tr rhc rlkscJ cx. rl)!on. Anyvnnalionorsc.li ?o315hvanv
<br />rlfli.n.! lbr0rEnir \tbj..rsrhc ot'tlic!rrronci!ilNnnxyorn.rmrcrhrilivchundrcdioll \r15fi))
<br />-1.
<br />a\ owrs ofrh. pmFny. or ny.nfloyccs wilh *oscs as rh.n sb con{Etrsari.n. *ill{l. rlf wo rlrhcimtxrcismi
<br />inrc'tcd or otitrcd ar {k lse 7044. Busincss (nd ltof.sn,N Codcr 'rhc Codrnc(tr s Licctr*- Law docr not lFllv lo !n o*tui or
<br />rhc Ireped, who bxilds or in{,roves rhcmn. md wlo docs such wod tinsc ll .r hc clfor rhtr,ughhis or hcroMcmll.vccs.
<br />fl,vidcd rhrr such impmv$Enh arc mr iddd.i orofTcrd fttr sL ll howcw. rll tuiHill8 or r{rotqEnr is $ll] wiriin nm vt]r
<br />ol con{'krbn. rhc O*nur Auihd *ill harc lnc htrlcn ollJrl,vin8 rlaf lE or shc did nor buiU or nqnnvc rlrc PDpdy tur rhc l'U{n{ of
<br />-1.
<br />as owncrofrh. tn{dy. .n cr.h{ntly..ftr.r i.8 wirh lice.se,l conr ror lo con(tucr rh pmjcd (Sec 7044. Bn'ncs
<br />and Pmr.\sion codc lhccl,nra.lofs t-iccnsc l-ow(loes nor rpplyk, tflowmr olProFnywln builds or nnrrovcs rl[tcoo.
<br />dnd sho .o ttr.s for such pmFck wirh Como.ro(t li(cnscd nuru h thc Codlrroi\ Li.cnsc hw )
<br />I! rcxcm undcr S(rion-. tl &PC lnrlhtrerrnr
<br />D.le: ()*n..
<br />woR(ElRs- aoM PFNS TIoN
<br />DES.ANAIION
<br />I hcEby at tuor undd ,uilry or'Frrury o c .ih. rolbwire dNllrlrtun\:
<br />IhrvcudwillNinun,nCcificarcoIConscnrloSclllnslrcforworlcr'dninnrdion.nspmviicdfoibyScllion:l?(X)ofrh'
<br />trbl, C.dc, fin thc rcrlbrN.. ofthc *o* fo! *hich rhc psnul i\ i$u.d.
<br />,l hlrc 0ff1will mdintain workcs cohp.nslrion insxroncc. rs tcquilcd by sccr ion l70o of rh. hbor Conc. lnr rh' r 'rnrnQot
<br />rhc work for shi.! rhir !.rm is ksuct My eorkda .omF.trsoln,n insut"n.c.rEicr and Fricv nu'hb.r sel
<br />RnicyNumbcr ExPncs
<br />dl rniryrh, in ihc 0dorroncc orih. work tu shichrhn Frnir h i!\ucd.l sl[ll nor.'nllr,v rnr l^-soo irldnv marncr
<br />v) N ro hcc.trE $bFr b rhc qo cr' conrFnsrnn, Irws .f C.lituflir. rnd rrrcc rh if I dFuld tB.m suhFcl brh'
<br />wortcn'corlpcnsrri(,nPolisn'trsofS.cri.n3?(Dolrhcl-rhorC(xlc.lshdl.ilnhsirhcoo{lysnhrhospmvhions
<br />W,{RNING kilurc k' {cuc trlrkcG con[cnelion corcragc is utrhwtul. ! d \hJl srb]c{l an rqrloJ$ b ninrinll Fturhic\ r'd
<br />nr'l n r\ uD r, um hu ftJ rhour
<br />-/s".,,n,,,ru,,t o,"l,r',c,,r.,n,"
<br />\p.,.,e/z/tx
<br />rxrr)r iI xd(lltitr ro th. !!\1 ol nrpcn\nrion. dinrAcs a\ ptuvid.d ld rhc
<br />DECIdBAIIQN
<br />I hcrcby ofilrm und.r r..,xyolp.rJury rh l,'nli&nslutrdctProvi\ionotChairs9{co'n@n.nlgsilhScclion7ln0)'fDiviri'n:l
<br />of rhc Aurimssand PrcfEshnsCdc. a mylicctrs i\ in rull forcc o.d crlccr
<br />t\."
<br />g q<z</<q
<br />e/zt/ tg .*,*"*", TkB L.'slr-ct,.t-'/^L(
<br />CONS'I'RI](ITION LljNDINT: A(]ENCY
<br />I hcEbyuinflnundcr Fh,lryoip.rjuryrhrr rhcrc hncoNru.li hndi'lsalcnyIrrncPcrr.nn.tucolrhcNorkn'r[ichrhisaalniris
<br />issucd 1sLr.3E)7.Civ C )
<br />lxnJc r Nrnr.: ---
<br />Lr
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Eneroy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lt/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certif
<br />/_\
<br />FINAL g-27-*.tutal
<br />Certif icate of Occupancv V \-/
<br />Notes Remarks Etc.
<br />MJ((/b!- ,J/v j'!2 i./C."-f
<br />1
<br />\..
<br />BUILDING- INSPECTOR RECORD
<br />Subf loor/Venti I nsulation
<br />( rnicr:-
<br />Ixtrdcrs Addre{
<br />-
<br />A.STUCANLDEILISAIIO!
<br />I lstby dinn u ndc. r.nalry ol Frjury om of rh. ftrlowin8 dcclml ions
<br />D.u,lirion Pcrmik-Ashcstr N.rificrrion Fcdcral Rc3trbrnrns ( lirl.'10. P!n6)
<br />_Rcqun d hns of Noritr.dh.
<br />I ccnilirhn rhc finumlr.!uhri,)nr rugrrtliL,N r\lr\tx rctrDvrl)rc mr rfini.rllL ri rhis |rtlo.r
<br />.{L7 L
<br />=
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