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SITE-WORK DATE IDiSIG.COMMENTS OWNER BUILDEi DELCARATION
<br />I hcicby rftlrDl utrrlcr n nrhy or!.rjury IhlI I.mcxcnu ln,m Ihc Co ra.lom l,icc.sc ljw tin rh.ltllo$ilr! rca$n (Scc 70.115
<br />au\irtcss an! Plnission C{rlc): Atry Cily or Counr, *hich rcquircs , Fmir k, consrdcr. ,llcr. irtrovc. dcBolish or qrn y
<br />itudurc, l]rKtrt) irs issudncc. also rcqutcs llrc lppii.rtrl tnr suchFmir (o lilc a signcd (,thcnr rhdr h.or sh. ic lic.ns.J !u^ud.r
<br />i, rhc povinnN oi ihc Conts.!tr \ I-iccnscd Dw (Chsfl.i 9, Comnrnc rg wxh Sccuon 7000 ol Dirision I oI Ihc tlusircs and
<br />Phtcrsons Cdl.) or thar hc or shc F cxcqrl rhcrcnom and lhc bass ny thc allc8cd crcmflbn. Any !n ari('n orS.cri.n ?0ll 5 hr an,
<br />amlicrnr tu d !.rhir srbj.ck rhc ryalicMl b i civ,l ncnalry .r nor morc lhdn l]vc hundrcd dollds (S5()(J).
<br />l. as oqncr ollhe popcny. or mycmployccs eill v.Ecs as lhcn sob uomp.nsalion, vnl Jo rlt woik akl rhc srdclurc i\ rtuI
<br />inlcndL\l or olttrcJ nx kh (SN.?044, thsines and Prctcsions Cdc Thc Conkacntr s Li€n{ lf,w dNs nor atl,ly b an oNmr or
<br />11[ p$pcny *h(r hilds or nrytro!.s r,rrdr dnd wln) docs n'ch Mtrk lrimsclt or hcrslfor rlnoneh ht orhcro*n cnpl,,y.cs,
<br />pmvi'lc'l thar \uch impnrrcrunk @ nor inr.'r,lc,lorollcRl Lr st Il,liJwdcr, d\c bui[in! or imtNvcmnr,s si] qilhronc yrd
<br />olconplclion. f, owncr Buildcr Mn havc lltr $unlcn or pn,vinS lluL nc or slE Jid ml build or irymvc llE poFny ntr lhc luqrM oi
<br />_1. xsowncrolrhc pmp.ny, amcrcldsivcly.ontadi'rg wnh hccnscJ c.nlr&lrs h !.trsflct lhc Oqcd (Scc. ?014. Busncs!
<br />Jnd lh,li:s\x$C()dc: Thc C.ntrcttr's l-i.crsc l-rw docs nor.firly b inowNr oi tro!.rty wh,' hnilis or impocs lhcrcotr.
<br />rnJ wh. coDra.hlnr$'.hpnjc.lswrrhrCo r,.r(sl liccn\cd pu^ua b rhc Cont&tr \ Liccnsc bw).
<br />I m cxcmpl uDdcr Sc.l bn , Ir. & P.C. li,r rhi\ rca)n
<br />!rcB6rBgCA!!E8NS4f!0!tpeqrlEArlo!
<br />I hcrcby ailirm undcr pcnnltyoltqluryoncolrhc li)lbwing declaratons:
<br />I hrvc mdwillmainhin iCcnnic{rcol CoDscnrro Sclllnsurc lir *orkc^ .onFnsarn,n, as Fovidcd ftrbyscct n-1700orrhc
<br />tltu C{r]c, titr rhc pcllormncc ol rbc work ntr shich rhc pcrnir is sncd.\a/_lhrvc Jtrd w,llrnJdJ wurl.r:'(,,mncn\Jlr{r
<br />'n\dratuc, as rcquicd b} Scclion]TlOoirhc L,hor Co'l..ltr rh. lcdnntunccof
<br />rhc work n, whrl rhisrcrnir is isNcd Myeorkcs .onipcnsarion insuEnoe.atrier a Flic, nlhh.r d.:
<br />/'a---cmr. q> L.L r
<br />1L8\r\ t
<br />I rnily lial nlhc pc,lnrnran.c ol lhcwork tu whichrhG pcrnrir is istrcd,I slBll or cnlthy ,.y tc^on r .ny nM.cr
<br />vJ rs b h..otu suhjc.i t, rh. wo,k.^ coml). rarn hwsorcalrronx,. md i-!rcc rlmt itl should hc.oN subjcc( tothc
<br />vorkds c.mpcnsarh Oovisions oiScclion 3700 oirhc Lahor Cqtc,I rhrll nnth*nhcoopl, virh tho$ pbvisn,n!
<br />WARNING: F lurc ro sccurc vnkcs .omlcnsarbn d,lcra8c is Dnla*rul, rNl shlll bjc.r rD cnrtl,,y.r (, crinnnrl ltmluc\ rtrJ
<br />lD oft hnn&cd lhotrsdnd dolidrs ($ldj,Oml. ir adJition t, th.nsirnJn, dr,tugcs ,s pi{,viJcJ ntr rhc
<br />S.cLon 10?6 of rl[ bh)r Cc{c, i crcs dnd alt(rrcy's fics.
<br />I h.r.by atlhh undcr Fnalryorl).rjuiy rlDr I {h lirnerl utulcr povision o, Chilrcr I (conmcncnr8 uilh Sc.rion ?000) orDivnn,n.l
<br />of rlr Bu\ .ss and Pn cssorsCddc, anJ nryliccn* is intull turcanncfttct.
<br />e-1f
<br />Liccnsc Ch$:-Licensc Nlnb.rl ( tto t:
<br />I -rt - z-.",
<br />I neEhy dtirmu cr penolry o, Frjury lhal rhcrc is | .onstdcrbo !:ndinr agcncy for rhc rbr('lmmc of lhc wort for *hich this lErmn is
<br />h cd (s.c. 309?, Civ. C.).
<br />AITLICA]JIDECLAEAUAN
<br />I lnrhy rltim udcr p.n,lry .r psiury onc oi thc iollowin8 dccl.niions:
<br />Dcmolilion PcrmileAsbslos Noi icarion Federal Re8okrn,ns (Tnb 40. PM6)t^z^---RcqukJ trrrc, ul Ndfi lrtrn.2<,
<br />j
<br />-lt.,nryrtu rtrc r.,ta,lr.ldlrrbr. r8.rJrn! rsbcn srcmu/rlocnoramlMblcn,IhrPlrFl
<br />-_+.d'ryrhrrIhrvcrc rlu\rnp[! irtr rr] {.k r h.r (nc abvc inlomlion is cotr cl. I a8rcc b conply wtrh all Ciiy.nd Couniy
<br />onjinarucs and Starc Law! fthing to building conslrncrion, ail hcr.by aurnorizc rcnrcsenl.lives oIthn Cit, and County lo e qll]on$e
<br />rh,vc nr.nrk,,.d nnilrny lar i'xr^.'c(ior
<br />/\pdicant or Ascnl SisnrluE
<br />),*. ,/Y-,-
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Rool Sheathing
<br />Framino
<br />ln s u lalion/En erg y
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />It4asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif .
<br />I
<br />FINAL L1 1t 'Lt Dr+lt?d,1
<br />Certif icate of Occupancy \
<br />Notes, Remarks, Etc.
<br />BUILOING. INSPECTOR RECORO
<br />Shear Wall
<br />oo^,n-L1'6
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