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SITE-WORK DATE ID/SIG.COMMENTS
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVlnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext.i lnt. Lath
<br />Brown Coat
<br />lrlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif.ft7 f/z-4,/z l)7
<br />FINAL s/L/ea /Z ct5,./"-,..y5- 4,
<br />Notes, Remarks, Etc.
<br />-+
<br />()wNuR BU!t-t)ul{ Dl],cA RATION
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<br />tltrsinds rnd Pd'cssion C.d.)r Any Cny .r Cnu v vhi.h rcqutcs r l.rmir to coninct, alrc4 improvc. dc,mhsh or rn n any
<br />$ru.rur,Frntroirs L*u c.. llso r.qtriEl rhc anrlica rlor$cnr.m b fil. i sisn.d irr.tu rhat lr or dr il lic.B.d pur$ad
<br />h the lmvirions of rlE Contelor's l-ic.nscd lj* ((:h!plc. 9. Co'nmrcing wirh S*rion 7(XD ol Divirion I ol rl.€ Blsinc\i and
<br />Pnntstr'ns CdL) o, $3r h. or stu n ereBF itur.trcnr aftl rhc haes ti)r rhe r llege'.I .x. n[oo. Aly vnfiriorotS.crhn ?0315 by atry
<br />rmli.rnl Iitr rp.rnir subj.c(s rh. rpplicrnrroicivilp.mhyolnormr.(hanliv.hu.dr.ddollffi($50o).
<br />l, .i o*ncr or rhc pmFny. or
<br />'try
<br />cmplqccs wnh wr8( ar rhcn sii compcn\diof,, lill do [r edl ud rlE {@u. h Mt
<br />iDr.Rkrl or oficrd fo' sL (Se.7O1-4. Busin.s bnd Pmf.sions Cod.: Th. Conttutols Lic.ns. llw do.s nor ipOly ro m orn.r of
<br />ItE DTp.ny wh) b{ilds or in{DH rh.E( ad wtF do.s sKh *b* himi.li or lEell or rhreurh bi! or h.r om .mplores,
<br />Fldvidcd rhar srch impDwdn( e. d inkld.d orollecd nn s[ ll ho*cs, 'l* h{ildio! or uipormd n sh riihin onc }qI
<br />ofcon]l)lr \ rL Ower BuiLJ.r will lR€ rlE b!rd.! ol pmviq ller lt or she did Dr hniLl or irlPo€ dE ,bpdy lor rlr pu4r$ of
<br />-1,
<br />No*rcrolrlE p6pcrry, um.iclusiv.lycontrdcrirg *irh lNtrs.! .oilRcr,h ro con(rucl rlE pol.cr (S.c ?O44, Btrsin.s
<br />a,vl pol&ibn(oJ. Thc Contnctor'\ Lic.n\e Lav dk\ rur rpply to an owRr oa prcpcny *lo bnilds or improv.: rh.r.on.
<br />,nd who ..otrrcrs aor such pml.c6 *iib n Conn b(s) Ii..tr*d pur\utur ro rh. Co.tracroCs Li.cnsc bq).
<br />-l
<br />anei€mfl u, er Setion-, A &PC forthiscr$n
<br />1lllaEE$--cquuils4llgN
<br />DEqIABAI!o!
<br />I hercby rflnmu.dcr pcmlryolpcrjuryonc.f rhc followirB dcchrarions:
<br />-l
<br />hrv. ord willnuirrain aC.nifi.deofC.N. r. S.lil.uE tur $o.kss' mmFNdio.. a\ povid.d ro. by s.crion l7m or dE
<br />L u Co c, tor rhc p.rlormM of rhe wolk lnr which rh. ft imir L\ i{Ncd
<br />_lhav.andwillnEintaiiKrk.c.omp.rssrioninsuranc.,axEquiBlbySdriotrr?00ofrh.tjtorCod.,forrh.p.rfomr.of
<br />rhc work for Fhich this pcrmn is isucd. My rorkcN' mmpdslrion incurdcc clricr ltn OoIcy .unt r r.:
<br />"",o,,' 9*xte f -^rl
<br />Iccniryrhar inrhc Frformitreofrhc wor k for whiclr rhir ltrn t ii issucd.l shillnor eq)loy my p.non in any mun r
<br />s .{ to hc$m slhiE b
<br />'h.
<br />w.t.6 @np.nsarion riwsolclriromi3. lnd asrcc rh3l irl stsull bccotu rbjer ro rhc
<br />woA.b conry.nsrion pDvnions of Sdion 3700 of rlE libor Code, I $all. lodhwnh onDly wirh rhos pmvGioN.
<br />IVARNING: Fiilurc ro .ccue q.rk.* c.hl.nsuinr. cov.dlc is lnldutul. $d shiu suhjcct e cmploy.r to dminrllEmlries d
<br />civil fin.s up b on. huftn.d rho!$nd dollh (Sl{x),U()0). in addnrn ro rh. cor "'r*,L"--
<br />rio[ dnm8cs rs prov'd.d for rhc
<br />S.crn,n 76 of rh. khor C(rI., inra.n and 8.orEr's 7- t-t-t
<br />I]1IT!EII.COIIA4(I]B
<br />u!tl!d!1J!1r\
<br />I hcft[y allrm uidd D.nrhyofrcrjury rhai I am liens\d undc. provirnn .l Chlnis , (comEncin8 wirh S.critn 7000) olDirision 3
<br />ol rh. Burmcs md ProlcsioB o)dc. a mylienrisintulltoreuxl.nc.i.
<br />r,i""n." cr"*,-1-6-alLr-i""*" r.ru.*.o
<br />C!}NIItrIEU!}NIJjIDINEIGEICI
<br />I ltEby alfr und.r lEMky of F.irry rh.r rlm ii ! .ornnd int L'dir8 .3d.y for rhc p.rloM. ot rh. *o.\ tor lhih tht Fmir k
<br />issu.d (ltcc :1097. Civ C )
<br />IISUEINLDEEIABIIIOI
<br />I h.ftiy nllm rnddr En.hy of perjry on. ofrh. folbwn8 dlrlamrnn\
<br />fJ.mliriotr P.rnrir $ Ash.{ 01 Nor itico( ion F.d.ral R.!uhIionl (Tnk J0, Pad6)
<br />R.qun.d k(d oi Noiifi drion
<br />-I
<br />!di, rhlt tlE f.d.El r.gul,rions Egarning ash.{os Emvd aE mr applic,bl. b ihis pDjer.
<br />i.{f .dit} ln.r I hlv. Ea.l fils app,irrion a,rl sarc rhd rh. abov. irromrDn is ioBr. I a8r@ ro lrmprr qirh rrr cirr .n,t counr,
<br />orJiDrr.s r lsr cLvsrcLri E ro btrildiu conntu.rnnl h.Eby rlDriEFp..s rariv.solrhi\Cirya,!lCounryb.nl.rtr!'onrl.,w
<br />BUILDING- INSPECTOR RECORD
<br />1-2015
<br />Erection Pads
<br />lJn,tc, \ ALldrc!
<br />ltx,vt rcdrn)ncd tn,p.dy tur -iD"t" I a/ La / LO
<br />I
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