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SITE-WORK DATE tD/str&'COMMENTS OWNl:R BUILDER DEt,CAI(ATION
<br />I hqcby rmm unda panly of pqjury rha I h dcmpr fmm rh. Coflir&roE t-i.aF Irw lorrh.lollosins r.Mn(S<70115
<br />a6'nd lrd Prcrsit Co<L): Any (il, or Coudy $hi.h Equir6 . Fnn ro oNnr.t, .,rq. imrmE &rfrnirh r rqn dy
<br />lrru.lrq Fid ro ns iBle. .bd ,.Sri6 llr @lia for *h Fnir ro frk. !i8n d .rBr rhr lE or nr i! li..B.d Fl,un
<br />ro rlE F.vbioB oflli Coirr-lor'3 Lica!.d L.* (CtuF6 9, ( ommdi,g sih sdion 70q) of rrirBion I ofth. A6'nB sd
<br />Fmlsio.r Cod.) o. thd h.or!h. ir crdpl rhdclion ind th.bei. for rt !lk8.d.rmption AnrynnrrionorstrinT0ll rbyMy
<br />.ppli.&n for . psni 3ubjRlr ln. rpplicol ro r cilil p. lty of not 60r. thd fiE hundr.d doll6 { l50O).
<br />L a o$G olrh. FoFry. m m' allph,6 snh *t86 6 rh.n nl. 6np.G.i!.. wil do ih. r(t rd rlE .nxiG . mr
<br />i,noxLd or o,t6td for d< {Sc.?o41, a6ilB ed ftofdhu CodG: Tn. Co.tr..to LtG l,w d,6 mr lsfly ro s.$,6 of
<br />ln prDDaiy whoh niL or inliov61lE6i. ndeno &6uch M him..lf or hdklf.r thrco8h hi! or hd own .nplor6,
<br />provilai thd ruch inlFo6Gnt e *x irnqi.d qolH 6r sL lf.lF*a6, rh. hiilding or in+.nEF ir $ld $nfii. oG )sof.orplri,! ttE olrc Bilda *ill h.E rlE hrth of Fori,t $i rE or tE dn bt hild d itrFow t E FoFry if, rlE F,F& of
<br />l{!l s oma or rtc pmpay. m crcluiv.ly cod'r! n! wnh l(6s.d .onkdoN ro conntucr rh. ,Nral (s6. 7ot.i. tlrsind
<br />ud PtlL,in Cod.: Th. ConlEdoar Lic@ Lr* {16 nor @ly to x o{E of prep.ny who build! or impmv6 rh66n,rd ntb N rtl. ir kh Fqdt lnh r Conr(o(.) li€E d polle o rlE Gdnaoar Li(!q t&,
<br />I m.r.mp uldd s.nion_
<br />D"r" 'lo-29 -\tp
<br />I hd.by.mrn tr.d6 Fuh, of pgjury onc otrh. follosins &.lurbtrt
<br />I h,v. orl will tuinllh . Carific.r. of (-oMl ro s.la.lNu. for $ nrkd onrFn d nrn, s lror id.d for qr s(ti)n 17ql oatlE
<br />Irbor Co<L Io lh. Ff(ffic of lh. c orl fo. sti.h rh. pcmit i inu.d
<br />I h.L.ind sillm.i.r.i. Mrl63' c6np<( krn idu.nnc.,6 r.qut.d brSdion:r7(nof rh.l,h)r(od.. nn rh. pdfotu.. ol
<br />th. worl aor whi.h tht pmit i! i$u.d My worl6 c.mraasll ion i6ur.ncc caria ud policy nunrba m:
<br />PolicyNumbd: liDn6
<br />|dfL-,6 ,r,", .,r'. p-r",-nc. orrh. {o* ror uhrh rhir Fmn i. &ual I ih,r R r orroy.nv F$. i. r.v m"*-i d ro h6om sbjd r. rlE *dra onF.t rn L*! of Cllifomq rn 4r th. if I slsuld t'(om sh.d
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<br />rlr
<br />$ 0*6' corp.Gdion FolilioB of s..ri,n 17@ of rlE l.kn C.&. I tlu[ rslh[nh comply *'n h rlr- Flrirhn3WARNINC triluc lo su. mrl6' snpaldhn cov@s. n unh$tu|. ud rh.ll rubjat d dplolE lo (mhil pditb !d
<br />.ivil ,i.6 u! to oDc hun&d lhormd dollE (ll0o.0o0). i. rddirioi lo th..on ol cohr.Ntioi. &ms6 !i prorid.d ror th.
<br />scrion 1076 ot rh. llbor ( ode inrE.sl &d dtoE* i 16.Kts,A)'ro- 2-B-lv a
<br />t t&iff t
<br />/Z DFCLATAIION
<br />my'cc"r.d u.,l€ F.rri'i of(L.prd ! tcommftrnB \ hsdnn7rtror.lUtrilnnl
<br />my/lk* 6 n rullro,e rn.fi(r
<br />I h6r6.r .lIr n !.dd FtrXv or Fjury thd I
<br />of rh. Au.,B ,nd Prordnd C.&. rd l
<br />1*1"*"*
<br />glxilBucrlaNrrlllMtc[!1:r
<br />I h@by rfiun undd Fulry of Fjurr rha rh6. ir i.on!ruclion ldriitrs.strr lor rh. pqfonMc. of rh. $orl lir trhich thi! Fnn b
<br />isu.d (s< 10q7. Cir ('l
<br />6&U(AtrL![{:lJAAIlq!
<br />I hdr:h, .lrm ud6 pd.h, oa Frjury oR oa rh. folk'Binr d(lrlt io.r:
<br />Dntulition PaTityArbdro! Norifi..lhn F.d@l R.guldiou (Titlc40, P!16)
<br />-R.qun.d
<br />L.tr6or&iiftrn.
<br />I cdity rhar rh. l.d6rl EsulllioB rcsrding sbcror r@\.1 ,c ml +plk$L ro rhb trojar
<br />llAU.*iry,u r r'.*,-a,r'i! .pplkdion dd $'r.rhd rh..hE rto'n'rion i3 cMrci I4rrrocomplrsirh.ll((!. 'nd('ounr,.rdine6 !d Sld. L.\r Elr!E
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<br />b{ildi.a .odtu.rtr'tr hoE. rqrstnn6 ollhi (-it! dd Counr! ro dr6 t .. d!.
<br />tu\c mdtni.d prop.nv for '6!..lhi
<br />Appli.rnl br As.nt Signrlure
<br />,.mnc i.D.{prinO:*r
<br />u"" .10 -Lg-tb
<br />4Ar.t,lO re -ro
<br />Sel Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathin s
<br />Shear Wall
<br />Framing
<br />D tl
<br />Ext./lnt. Lath
<br />Brown Coal
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />D uty Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />FINAL I
<br />Certificate of Occu n
<br />Notes Remarks, Etc.
<br />{
<br />BUILDING. INSPECTOR RECORD
<br />Erection Pads
<br />lnsulation/Eneroy
<br />Handicap Req.
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