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SITE.WORK DATE tD/srG..COMMENTS oWNER BI.]II,DER D}:I,('ARATl(}N
<br />I h6cby tnnn und6 pdllry ol psjury lhal I dn .(opr frem rh. ('enrr.1os' l-ror. tis fo! !h. illlowins r.r$n (Ss 701r !r
<br />It6in6s .,i Profdio. (ii.) A.! ( irv or Countr *hich r.qut6 ! ,sfri t. codrud. rlts, ihFo\e &nolirh.r Erstr an!
<br />{ruduq Fn t. irs smc. rho r.qutc rh. rpplkd f(tr s.h Fm ro lik . s'sn<d {d.l6r thr tE or ih. 6 liqed l,{Bdi
<br />k, rh€ F.r66nr oa0r (bn!r&r64, Li..nrd l:s ((Lprd 0. Comh*i.s sirh Sa1i,n ?(x)0 of lhision I ol rh. tlusln6r dnd
<br />Prolcsions (-odr) or lhar tE or rh. B.r.nfl !ho.6oh od rh. bosis lo, rhc llkE.d.tdflnrn Any rmLri.nofssrxr 70:r I t by,ny
<br />stplica toraF.m suhjalrllEapphcinllo!civilrcn.llyoanrnor.rhdn\.htrntlr.ndolldr{rslm,
<br />l.so$E.Irh.F.Fn!,dm\mph16trirh{!*6srh.irFk(.nFsnn.s'll&rlEtr(\snrlEsrrr.6Fr
<br />mlq'd.d oro,rd.n for sl.(s( 704J. Busind Md Prol*F6 Co& I hr (tdr.cror s I ic@l!* dnml ',ily
<br />kr s.\nddf
<br />rh. FnF.n, *ho tlildsor rmFovBrh66n, dd who do6 nah wo hnnr.lforh6s.lforrhmushhiso.h6o$rarploy.6.
<br />f(,vidcd thll ru.h iolr.rlBrs c mr hralr.d or olldql Iitr ek ll h'$s.6, !h. trrll'n8 ar inB\ffir ir s,ki *ihin o.. ]6
<br />olmtrpLrio.. rlE (xffi B{i&r q lE\. rlE htrdo olFonns thi lE or rlr dd ml txild.r r[F\. tfi. ,,qEt! aor rh. F,rre or
<br />I, dr o*nd.trh. !l$F1y. m.rclusi\.1, c.ntradinl wirh licm.{ ronrddoB ro $nirturl$. Fojdr (S( 7011.llrF'ns
<br />ntri PFtsrhn (i'd. t h. ( \nt&1of! Li(.nrc l-aN do6 nor .!ply ro o os n( oaroFn t sho bu,ldr or impro\ B rh(mn.
<br />t.il \ho q,drrls lor ruch FoFls r trh ! (tntEdorl.l lirds.d r!6d kr rh. (ntu doi. Ltmk trtr ,
<br />I tun.r.htr undsSdrnn
<br />I).r. Ornft
<br />t\ oRxrRs; (-tlPl:i\s,(TioN
<br />DIIJJEAITAI
<br />I h(.b) aflim u nds pqBlt\ o f tslo.! oft o I rh. follNr 'n! &rldarxrB
<br />I hrv. eri s i l l mainrain . ( dili.ar.ot (irtudr b s.tl tneur. tor \wk6'comli. dion_ d lrovd.d for b, s(rtun !700 orrh.
<br />I ltnr Cod€. tu rh. Flo,1,@. .f lh. u.rl tor sndr th. psf,it ie iatu.d
<br />Ihr\.and$rllm!tni8'rsorlsscooran€rkrrNtr.lE..6i.quncatb)SarionrT(x)rlrh.L.lxr(i)&,finrh.tEfomMc.or
<br />rh. trort f.r whi.h lhic ,.rB( B 'su.d My*orkqs'.omn re.tion insurm(. cnid &l rx,li., numh6 tr.
<br />Pol'cyNumtE [rptr*
<br />t{*fa ,*, ,,*
<br />^^,mffi.orrh.
<br />}u,r ror *h,ch rhi! pmir r Ltiucd. r shar mr mpror oy p*,n in lny n,unoL B
<br />'o
<br />h.cnR tuBd ra r h. unrt 6' .nnFsrion h*! nf ( rlifom( Jd .gN rhd if I druld b..o.'. obrer ro !h.*o.t4 .onqEtnion F\6hd ors..ltu. 1700of rh. litn Code I llbll. fdhsnhsmpb Enh'lrr FnrtioB*ARNINC f.ilur. ro su. $!116' c.mFMio. .o\n rc is unLstuL d lrull tul,jcr D @pl,rE b m'nd FBhE ind
<br />('vrl lin6 up h on. htrndrdl rh.Nnd rlolltus ($lul,(xx ,m!.Ntnn. .l.nRg.\ !s p!.\tr!.! lir ih.
<br />s(tion 11076 of lh. bbor ( i"-L. i.r66l and r onry r
<br />,,.,., 5-a ].lot )
<br />I lr'rhvalli'trrunlls ptnrlrr olt{M\ rhir I xn I'coerl i Iro\isi(r ol'('h.prd'J lconr trirh sdid TlInr o,l)nki,r I
<br />or lh. trurlns ind Pmf(nons ( od.. nl N lK.e B
<br />'n
<br />rull nn.t dxi .rT--r
<br />15
<br />,n a .,{d) 40/ /,"",,.,,.,
<br />') 1 o brR.l5N "rr1 d//o ).
<br />(-oNsTnu( TtoN LErtDrN(; acElt( t'
<br />I hdt6y allnn undt Fnrhy ot p.rJury lhil thqc ir a coNrru.lion hnding +6.y for !h. pafoman.. of rh. work for $hi(h rhir p6nn is
<br />iqu.d (56 tlR7, Cn. C )
<br />AtfU(AALDf(!.A8AIlaB
<br />I hEilr ,IEt utd.r Futr of FJU,I-I oE oa rh. follo*m! drladio.r
<br />D.molilion l'(mtrrAsbdor Norificriion F.:!6al R.suld ioB tTn h r0. Prn6)
<br />Rlqunol l.drq of Mrifi (dhn
<br />,.*Qr hf,n. ,,*,o.r,.sur.t.B r.*dhr 6b.eo,m\.r r. ft{ +pr*.bk ,. ,h( Fnrd\-
<br />lcdtifythd I hav.r.idrhir.ptli.aiio.andlllrcthrl tfi.ab.v. infomarion ts cor6'i l.NrEtocomnlysnholl(nyindCoutrry
<br />odmncd.rd sur. h*r Eh!$s ro b!'ldm*.oldrudnc sd lEq'6, NrrFru. rcFsrdtr 6 of rhB (ir! e'l ( ourr ro orc up.n rh.
<br />.bn,. mrreE{ FFiv for 6Eiitid*, ,/'l 1 l
<br />Ap,,d or^rd,sru,uE [,th/ ./! t"V , o.r..f ] 9-., o/
<br />Pffihemm.,prin,,: EktUdAA / /OPzz-.I
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenUlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />D all
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Mason
<br />Pool Fence
<br />T-Bar
<br />Handica R
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />lt )
<br />FINAL I b llAltt .L
<br />Certificate of Occu n
<br />Remarks, Etc
<br />BUILDING. INSPECTOR RECORD
<br />Forms/Steel/Holdowns
<br />Notes,
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