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SITE-WORK DATE tD/stG.COMMENTS ()\\ \r;R ril ll.rn R r)l.l ( \R 1l l0\
<br />I hcrcby ritum tr.der ncnally oi rcriury rhrr I m cxcmrrr tmm rhc Coik&nN Li.cn{ LiN n, rhc foln'wine rq$n rsN 70.11 5
<br />Dusincs r Profc$ion Codc) Any Cir, or Coutrly shlch rcqutc\ r lf,nn b coNrru.r. alrcr. improvc. dcnrnnh dr rcnrn r y
<br />(nrclurc. prio lo ils hsulncc. llso rc+tcs rhc rpplicanr tn skh Fnnn b iL a siSncd {,rcnrd I hal he o. df, is li(nsd Nrsurtrl
<br />t, rht pmvision\ of rh Conkr.kr's Li.crscd bq (Chrlrcr 9, Cu rnrrcin8 !irh Sccri,,n 7(XXl of Divisidr :l oI lhc Busi.c$ rnd
<br />Pnr'csshn\ Codc) or rhrr h. or shc hcrcnrpr lhcrclionaod llE hasis turrl[ all$cil cxcn,,ri( r Atryviol.rionoISdionT0.ll5hlrny
<br />lptli.nrli,r,pcnirsuhjc.(rhcafflrrtrrroa.ivil,[Mlryolnornxnrhanlivchundrc.ldollars(S5U))
<br />-!-a\
<br />oNncroalhcpmFny.(rmyc DkJtccs wirh wrs.\ ds rhcn q,k compctrq bn. * ill do lbc trorl ,nd rt* (nfu n n
<br />iirrnddl or olTcrcd lbr srlc (Se 704-1, Busincs otrd Pr.fcssn,ns Codc: lic Conraci{n\,-i.nsc Lrw docs n.r 0rtlly ro an o*ncrof
<br />rhcpmFny wh.iuildlor ir{mws rlrd4 ond *lD dB uch eo* hm\clfnr hcrrll or rhDuCh hi or h.t.sncmplorcc\,
<br />nrcvidM rhur such inurownrnh m ml inrco(H or oliirn for {lc lt how.r. rhc hu'llling or ir{,ft)vcmnr is v'kl sirhii onc lrn
<br />olcomthr i,n. rlr O$ncr Brikhr will haw rlr burilcn or pn,ir8 rhd rr or shc did nol huikl or in{mt ific p JFny n, rhc NIFE of
<br />4frrwnr or rtr, pioFny. nm cictusnrly conl.{d in8 * ili liccnscd conrrrct,s b ..nNtu.r I h. pioJccr (ss 7l s4. Busims
<br />uod ttri$stin Codc lhcConrldo.'\Li.cnscLdwdocsnoloprlyro,tr.w.crolropcnywhohuildsorintmvcslhcrcon-
<br />,trd who..nra.r\lorsnchpmichwirhiconrndo(9liccna'dpurulnrhrhccoilfu.d\Lic.n{trs).
<br />I xrcr.trlPr u c' Srri
<br />Dole: Oener:
<br />WORKEN.S CIIVIPENSATiON
<br />DICLAXAIION
<br />I hcr.by affirm u.d.r penally or p.rlury onc oflhc rolhp,ng d(ld.rtuns
<br />-l
<br />h.vc dwillmrinr"in"CaniltrflrcofconicnrbScliln\ur.krworkcG conrlrcrsarion. !s pn,vidcd ior b, Sccrion l7(Xr ofrlrc
<br />tihor Codc. Ior thc pcriornmn.. oarhc work ftn wlrich rhr p.rnlir h tludd
<br />XJ havcrnd will 'nr.ir Borkcr'c.npcn\arion iNu6ncc- N rcquncd hysccrtun r7(I)ol rhc L$otCodc. hrrhclr.rron ri..or
<br />rfu wort tuwhich rhi(,icnnir is i\sKl Myworkc( compctr\rri,)n in\urrn.c.rfticr drni.ynunrh.r (c:
<br />-2.*-ic *
<br />^*,n"
<br />a7 5o lt<l ro /t /tt
<br />-lccnilylhar
<br />in rhc pcrforroncc of rhcwo f(rshichrhisr.rnir t nsucd. I shall n l cmploy rDy l)trsi i'r rtry nrrncr
<br />v, ds ro h..onr suhAl Iorhc workcrs conr.nsr|iotr hwsol Culifnnitr. r r!r.o rhr rrl shruld hc.olm subjcd lortf,
<br />q.rkcrs..nrFn\dtr pBvsionsolSdn,n:1'7(rO frh. ljhtr C{tc.l rtall. f.nhwirh comtly sirh rh.c pmvi\ions
<br />WARNIN(i: FrilxB t' surc w)rkc$ ..mlcns.ri.n covcrrB. rs unlrstul- rdd rhrll \xbjNr an cn]Plortr ro cn'nimlI.nrlris rtrJ
<br />.ivil ritr.s up b otrc hundrcd lhounod nolltrn (Sl()1J.UJo). in 3ddilifl ro dr. rod ot.omFns,rion. drnu8cs u\ Pnvnlcd rd rhc
<br />s..rirr:lo7r)olrhc l.rlxtr codr. iriclci rnl dktrf.y \ 1..r /2;/rrts'
<br />DISJNAfION
<br />I hcEby amirnundcr Fnahy ol !.rjury lhlr I am li{nEi undcr provision orchrfl$ 9(conrmncin8 wilh Sccri'n 7m0) orDivision I
<br />ol rhd Bu\irsslnd Por.ssions ('odc. md flryli.ctrsc is h lulrlorcc flnd cflccr
<br />1to t&c+
<br />t /z/rv $ o",t r.td -I-,^tSi- a+a*-7-1 6"t 5
<br />CANEIBICUONIENDINGIICII.CI
<br />I ncrchy lltirnundcr rrmlryolp.rjuryrhnr rhcrc is r..n{rucrion bndinB trgenc, ior rhe Frrolmn.. ofrh. lork lor sirich rhis P.mrir is
<br />hqrcd (S.c 10e7. Clr C )
<br />I.cnifyrhd lhc fcdcsl rqularioni rcgrding lstf,do\ rcnbval rru n.ramli.$lc lo lhhlroFr
<br />ll .c iry rhar I havc rcnd rlris .mlicd iu md sl0lc lhnl lh€ ntx,vc i'r l',inrur ioi t ..nccr I nSre h oarPly wirh !l! Ciry md coutrl,
<br />.rdinrrcs rnd srar. trws rclarins to buildins conslrcrion. rnd hcrehyr hornc ruPrc€nrarivcs ofthh Cny lnd Coutrr! ro cnlcr urn rhc
<br />stslc 'rcnhnncd nr,ncny ntr 'n.1ur96n1E _
<br />noorr.,",.,nu,,rr**,"n 40ff - *^,s/s lzig
<br />,"^,."^,.,,n"u, ?ti!+ rr+"tto)
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Shealhino
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certil.
<br />FINAL b/zrlt ,/h KL
<br />Certif icate ol Occupancy
<br />Notes, Remarks, Etc
<br />BUILDING- INSPECTOR RECORD
<br />,.,**"
<br />"r.. -_lQE- 19{ lb r.iccnsc Nun,hc,
<br />AIILICAILD&CITIBAIIQN
<br />I hcE$, ffnr undcr pcnuliy oI Frjlryonc orrhc nnbsin8 dccldarions:
<br />D.frrilion PrmnrAsbcsros Norificarntr Fcdcral Re8ul.rtnN ('l irlc 4lr, P,n6)
<br />RcquiMl trtr$ of Norifi qlion
<br />I
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