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DATE ID/SIG.COMMENTS OWNER BUII,DER DEI,CARATION
<br />I hcrcby anir under Fnolly o, n rjur-r rh.l I m cx.n{'r ri.rn rhc Cotrkrcrors' Liccn\. Ijw ror rhc f.llowitrB rc$on (sc.7011.5
<br />Busincss rnd Pr.r.ssnrn Codc): ny cirt or Counry which rcquircs ! pen.it t, conslrucr. rlrcr. inDrovc- denFlnh or rcn,tr rny
<br />slrucruc. prir b ir\ is\uakc. also rcquircs rhcnppli.nnr f{tr \!.hFrmir Io filca ri8n.d srr.nrnl thnr hcor*h. h liccn*d J)uhuMi
<br />b rh. provi\io.s ollhc Conlructr's Liccnscd Lrw (Churrcr 9. Commncins wilh Sccrion T()OO ol Divjsion I orrla Bu\inc$ anJ
<br />Profc$i.ns Cudr)6rihDr h. orshc arcxc llrrhcrcliofrlndrhcbssislbrrhclllcgcdcrcmprion A.ylioLrn ofsMrion70:lI5 byany
<br />applicanr tor oFmit subjsls lhc {'tlicrnlro rcivilpcnalyofnor nBr. rhM rlvc hundrcd dollrs ($500)
<br />-1.asowflcrofrhcpmpcnr.ormycmplolccswirhsagcs
<br />sihrn v,b contfin\d n'n. willdo rh. work,^J lh. nmtm i\ tur
<br />inkBrlr! orollcrcd tn salc (Ss ?(84, Busincs od Phltsions Cul.r Thc Co.lrlclols Liccns tjw docs not lplly b anowncr oi
<br />rhc pmrcnt sl$ hxilds or twhh h.mn, dnl wh, d,rs {ch klrk hir\.lfor h.r{lf.r rhmrgh ik or hcr own cmpbyc.\.
<br />Fovidcd rh.rnrch m!(wnrnr\ m tur i,rcidcdoroficrcd n,ek lf- h'*c\q.th. hliklins or nnpmlcn$t is v,U snh'nu c )rr
<br />of.on{lcri,n. rhc O*ncr Buiklcr willhtrv.lnc hrdcn ollmvnr8 thnr h. or \hc drl nor hxild or inu.vc rhc rmFny nx rh rurFe of
<br />-1.
<br />!\owncrol rhcr()|Eny. amcxclu\ivclyco rrclin3 with li.cnscd conhchN t' cotr{n'cr rl.. D$jcc! (Scc. ?014. Bu\ir'cs
<br />rnd Pn,li*sion Adc:'I hc Coirm.tn s Liccn\c t-aw do$ mlalply to ano*ncr ofF)Icdy who huikls or imprcv.s ih.r.on,
<br />and who conr&.Is lor such pro)cct\ wiih a Contmdon n ltcnscd NAu,ni ro rhc conrn.rtr l Ltccrsc tiwr.
<br />-l
<br />lmercmDl undcr Scclion-. B. & P.C. lor rhis rc.en
<br />Dal. Om€.:
<br />tloaKE&r!0uf[xstroN
<br />DIi(;IAXAIIQN
<br />I hcrehy rllnf, und.r I)ctrrlry ol !!rjury onc ol rlE li)ll,,uing dc.l dtrrN
<br />-l
<br />h.vc rud uill mrinrain a Ccn ifrarc ni CotrEnr ro Sclr-lnsurc frr workcrJ..n!*nsarn,n. r\ p[,vidcd for b, S.clion ST(x)oirhc
<br />trbor Codc. f(tr rh. psforfrtuc of rh. work fir whi.h I hc pcnnil is i\sucd
<br />I hrlc and *illnuiohin workcrr'conrpcnslrion imumncc. r( rcquncd hyScdFn 37(x)olrhc ljhorCodc. lnrthc |Erlinnrnccof
<br />ion insunncc .rric. rnd Fli.y Nn$cr ffc
<br />lccn'ryrhrr ,nrhc ncrformruc olthc sork,nr thn Nnnlr i\ i\\ucl.I \hrllnor.nlpl,,v Jnypc^on in rnr- nrtrn.r
<br />h N nJ br(nf, subjL{r r. rhc RorkctJ .omFnsd t,n hw\ of Crlift,nir rid a8r.. rhdr 1f I s,bxlil h. f,subj(ruttE
<br />workc^ c.'npcnsriion pb!is6n\ olsc.Lon l7(x)ofrhc lltxtrcod..l \hill. tudhwirh.o rplt sirh rho{ prirvNtunr.
<br />WARNIN(; FailuE k, sulc $ltrkcA' .onrpersarion covcm8c is unhwtu. and lhill slhlccr an c'nploycr lo qi'ninal pcMlrics rnd
<br />.ivil ,li.! !p t, on. hundrcJ rhou\ nn dolhrs (Sllx)-0lx)). in rddiiion ro lhd cosr ol compci\arion- damracs a\ prclidcd ftn rhe
<br />Sccti,n,:l076olrh.lrtxr(inlc. i' rrc{ rnd arktrmy \ lrcs
<br />Do,zn Pz.7z1 /, - >5/ze/ fi
<br />t (:ENSr:p l-QXl Mllll
<br />DI(LIB{I!!]N
<br />I hcrby rmrnr undcr ,l.Mllyolpcrjury rhal LD liccnwr und.r rovirionofch,pr.r 9 (.onrmn.in8 wilh SR..tion ?uJl)) olDirision I
<br />or rhc Blsirc\s and Pm{csions Codc. snd
<br />'ny
<br />liccn$ in tulllbr.c md cfEl.
<br />-7olqt ?
<br />r)al€ 4tza,/fl (in,r,(,,,. Dc ero"y P.oVt, /;rs
<br />CONiIBUqI!}NIEIDING&GIICI
<br />I hcreby alfinnu cr lEn(lryofpcrjury lhal thcrc is r on(fl.rion lc.dirg ascn y lor thc lxrrbnurcc ofthc work fu *nich lhn pcnnil is
<br />issu.d (Sc. :l{}97,Civ. C.)
<br />d.tfuraNLDli[LtS uax
<br />I rh-ht dltmundcr |tmlry olf.rjury onc oirhc lnllo*ire dcclararn,n\
<br />Dcnnirn'n Pcirnic Albcdos Norifioriotr Fcdcrrl Rcgulnriotrs (l iltc 40. Plda)
<br />Rcqun d lxrrcrof Norillcdn,n
<br />I.cnrlyrltur rhclcdc,.l rc!ulari(in\ R!rdi'r! r\tf,!osrcmrrlrrc or rpt, i.rUc t) rhi{ t)rol..r
<br />.rh,,! rf, ri,'!l|n4{d\rr .ttr.ri,nIrD,!t,
<br />Anpricnnr.r^*enrsi*nrrurc. *4--'\--- t^r" 5/Zl/tt
<br />4.5e itr/
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />Subf loor/VenVlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq i -/k/6 .//eS/-q)
<br />I nsu lation/Energy
<br />Drywall I , -fi-t6 -l*(.lo €i)
<br />Ext./lnt. Lath
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />En Final Reportgrneer
<br />Flood Zone Certil
<br />FINAL )-1-t9 J),9o*,(t1)
<br />Certif icate ot Occu pancy
<br />Notes, Remarks, Etc
<br />BUILDING. INSPECTOR RECORD
<br />SITE-WORK
<br />SLAB Floor
<br />Brown Coal
<br />rh. uo,k lnr ihi.h rhi\ Firnir i\ i\\ucd lvly$or[cA
<br />L.nd., t Addr.*'
<br />-
<br />7\
<br />I
<br />I
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