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DATE ID/SIG.COMMENTS OWNTJR BUII-DDR DEL('ARA ION
<br />I lffetry ailid uhdd p€nally ot p€rjury lhal I an e\€nrpl frcnr lhc Co r.doB LiccBe L{w for Ih. follosi,rs reMn (5(.?011.5
<br />Ittrsinss and l,lol$ion cod.) .y Cily or Colnly shich r.qni6 a p6ril to constDcl. .ll(, nnprcre. dmolish nr .efitr ant
<br />srnrcrure. pnorlo ns isuanc€.0l$ rcqtrte the.pplicr for $'.h Fnnir (. lile a sisn.d ra'chot rhar lr or sh. k licms.d pu6u&r
<br />lo lhe pm\Gions .f rhe conhctol'3 l-re.*d Ii\ (Chapr( g- Comracitrs Nirh s..1ion 7000 ot Division I .f rhc Insi!6s and
<br />Prcl6sions Cod€) or lhal n. or she is.rdnpr rh6.fron onJ rh. bais lor rhr rll.!.d.$nprion Any iolati.n ol Sdion 70:l I t b, a.,
<br />aplli.a aorat]mnsunj<rsthe.pDlicanlloaciv'lpcn.lryoanolmo,erhanfivehun&eddollss($500)
<br />l. as oNn( ol th. Irop.ny. or my enlloy6 wilh solB a th.n $lc .omlEnsd nin. \ ll do rhc $& a.d lhc nndurc h nn
<br />inrm{jld dr o,le'ad fo, e1.1Sc.7044. Busin€ss and Prof*sions ( ode rhe Conlraciois l-icosc 1,0\v do6 not rpply lo an osn6 ol
<br />rhc peps1, \lho builds or i.prov6 th6on. ed $ ho dG su.h Nork him!.lr or h6.la.r rhhurh hB dr hd o n employ.*.
<br />prorid.d rhlr such im!rcvonols dc nor intdld.d n olId.d for slc ll hos6-, rhc buildinE or i'nFovdn r is etl \irhin one )a
<br />ofcompldion. rh. (\h6 auiur \villha\. rhc b'nl6 ofpm\i.s th{ hc or sh. dxl6r t ld dr nnFor! rh. p!!td1y ror th. puqxrEoi
<br />l. as o$.o olrlE prupdr, an cx.lusiv.lyconta(tinr {nh hce.scd . o,rracl o 6 k, consrtuct lhe pmjecl (Sr. 7(}1,1, BN!6
<br />.id Pbltsion Cod€r'rhc Conrracrois l-iccnsc Las do.s hor npplr ro anolvnd oi'propdly who btrilds or improvB rhdon,
<br />and Nl'o cod.adsfDr chpojers*nha(.ntacb(s)lic€nsedpu6ua n, rlt C{nlradois l,icos tj$ )
<br />laoetempt u.derSe'ion
<br />Drre Ownerl
<br />TVORKERY COMI'8.\SAION
<br />D!'EIAAAI]OI
<br />I hdcby amm und6 td.ltyolpEjuryonc oalhc follo\rint ddmrioc:
<br />Ihn\cad\villnAi.rainaCqlilic.rcolConsqrroS€ll.Insor.forsortmconrDgsrion.asDroridcnforbySErionlT00olrnc
<br />tjho' Code rorlhcpgfomanc.ofthcrvork forstichrh. p6nn is issu.n
<br />Ihr\e a \rillnrai ain\rorkds conrNDsarlon iNtr'.tr.r. {s
<br />"tr 1. 'l fL1 .\l'i.l rl'h r crtr'r , )n.u I M\ {rrl,o, (('trr<, t(in,rr s+d< p;*t,
<br />Po,,.,\u {, qob lt l1
<br />r.quir.d b!s(ri :17ff)oirh.l..ho' C.dc, lornElcrtunh..ol
<br />nr. insurturc .a n ier dd Dol ic! trrnbd tuc
<br />t 7{..,,-:l>+/.-
<br />I Gliayrh.l in rh. pdf.nnn(. ofrhc $ark for shich rhis rErnril is ksucd. I shall nol o$loy any p.Mn in any [oncr
<br />c, m lo LsonE subj(l lo lhe \ortsl .o'npMion los s oacaliionia, an isre rMr if I should b..on subj(' to n'c
<br />\orkss compenslion piouisionsolSectn'tr l700 olthe l-,lbr Cod..l sh.ll, rodh$ nh corplr *irh rhokpm\bioa
<br />wARNING: Failut lo *cue \rort6'.or.p.Mlio..o\cm8. is unla\lul. atrd shall subj{l arployd to dilninal penakis d
<br />cilil fin6 trp ro dn. hundrdl rh.ue.d dollaE ($100,000). in ad lo nr (on olconrpenFrhn. da.aB6 as pRrrid€d for rlE
<br />1{,76.|rh. I ilnr (.n. i' .rar ii,l
<br />10 I s-/ t1 [ \,&0
<br />.J,"e *rr, s<i"" ruoor "ro*i"." rI hftby afim undd pa.lty of lsjury rld I an licctr*n und6tJl!\isiotr of( haEn e (corr
<br />of lfi€ Busin6s oodPtuasioNCod.. and nry licdrsc is in tu ll liri.e dd ctt.r
<br />ts
<br />/tr/,+ Y x,,iz.rz*e
<br />1"" r0
<br />I hocby rmm lndcr Frolryofrerjurylhar rh6€ is a co.slnrcrion l.nding agcnct lor lh. p6 ioil lrlr \ork ior $h ch thh |Enrir il
<br />Bsued (Ss loq?. an' C.)
<br />t.cnds s NaE.
<br />APILI(;\NI DECLARAIION
<br />Ihs$yafiinnundcr paahy oapBjury onc oarht aollo\nr* deldations
<br />l)onohnrn Prarns-AslEstosNolificdion t-.ddal R.gu,al nrni Onk 40. P.n6)
<br />-
<br />R€quncd L.x6 ol Mlific.tiotr
<br />I culily Oal rhe fcdaal resularioG r.sddins ab6los ronoval arc not applicable lo this pmjccl.
<br />-+:+cdiry lhat I hlE rcad lhis applkalion ed sl.te lhal th. rt$v. infom.rion i! .oftdt I agre to comply *nh all cny md ( oumy
<br />.dinanc6 6d sralc l.aNs Ehrins ro blildul.! co n.d n6eby .othonzc rqrdmrdi\ s oflhis ( nymd Connlyro dt6 Wonrh.
<br />ah.ve nBi ioned t, otd! lor
<br />\LZ.r^ y
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenUlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing i-fm-qgr {v>/
<br />lnsulation/Ene v
<br />Drywall
<br />I ,OT
<br />I
<br />Ext./lnt. Lath I U\<_-.'
<br />Brown Coat
<br />l\,4a so n ry
<br />Pool Fence
<br />T-Bar
<br />Handica p Req
<br />De ut Final Re ort
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL
<br />t)
<br />rl s1 la -I /y>)
<br />Certificate of Occu pancy I 15\(:-r,
<br />BUILDING. INSPECTOR RECORD
<br />SITE-WORK
<br />!i; el^-p
<br />CJ/.,:a4
<br />K:lktq
<br />It.wa
<br />)tt Z,)
<br />Notes, Remarks, Etc.
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