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SITE-WORK DATE ID/SIG.COMMENTS OWNFJR BUILT}ER DI]t,CARATION
<br />I hc(by drl,rD undcr pcndlty,, p.rjry rhar I m ci.rhln ft,m thc Conrrntrr l,rcn\c L,w f(,lh. tufireina rcrY (S.c70.115
<br />Busincs! an! Pdc$io! CGrc): Any ciry or Counry whrch rcqutcs r |1.m !) .nn{Nl. !llc.. imlove. Jcmol$h o. rPrir .nv
<br />dtocrurc. pid b s Nsuancc, tho rcquircs rhc,Ipticmr Lr \ur[ rcrnnl kr lilc { \i3ncd {rr.nttrr rhtt lrot sh. is liccn*] Po6uanr
<br />b rh. truvision\ ol rlE Conta.tx s l-irtr\cJ liw (Ch.fl.r 9, Com.Emi.8 with S(rbn 7OO0 t Oivhion ll ol rh. Irr(in.\\ xid
<br />Pdcsions Cod.) or rhar hc drshc n crcry]l lhcrcIronr !n,l rlE hrst nrrh. !U.8cd .rcnDri,nr. Any vi,thrn)notScclion ?lr'11.5 hv lny
<br />appli.a tnr. p.nnn sublcck rhc lpolicul t, rcivilr.nrlry.l nor nue lhrtr livc hundr.ddolld\ (S5m).
<br />L as ovnc! oirhc puo.ny, or nycmployccs wir[ !a8cs a\ rhcu n,l. conFn$ti,n]. sillito rh. *ork &i rh. {nErw is En
<br />inrenlc'l orof.r.J liJr elc (Scc 7044, Bu\inc* dnd Pnn.lsnnr CGL lh.Conr.r&r's l-iccn* Lrw i,Es nor .plly h .n oamr .f
<br />rhcFrpcdy wh)buiu\or mrh6 rhcB)n, lnl who Jr\ \uch *on tum\.lfor hcn.lforrhn,u8hhrorhd ownconloycc\.
<br />rlvdcdrharsu.h inrpn,vcmnh m n nrchJ.{ d o|cEd lo siL lt: hoevcr. rlE I'u rlhll3 or rlpft'Kmnr i\ {,lt wnhr.m rd
<br />of ohplcriJn, rhc OwNr Bni!,c! will hrv. rh. buftln ol ttuvtrrg lltrr lt .r rh. Jil Bn hudd dr r{ro{ lhc F)p.ny foi rrE lurr$c o,
<br />I. r\ owi( of rhc nNpcn y, an ciclo\iv.ly contdcury un h lMtrti .onrrr.t'c nt coh(rucr rlE F)jccl (Se 7(144 Bu5inc$
<br />! l PDtssi{ CoJc:'rh. Cotrttcrr's Lrcnsc l.awJo.s not rpplt6 dnowncr.l ln)pcny *h(' bo,Ui or rmlroves rhcrcon.
<br />aM who .onrErls i)r such In,ir6 wnh . Ci,nhcn'(n htns,l pururnr r, thc Conrtlcttr s l-ircnt Uw)
<br />l.mc\.'!pr un,l.r Sc(r
<br />ttOI.KERS' COIIIPENSATION
<br />![lllISAJlON
<br />I hcrchy s,inm unJ.r pci.lry of Pcrlury orc oilhc irnb*uE 'lcclrrarn,h\l
<br />-I
<br />hrvc ail wru m,nlain r C.n ia(arc of Con{n( ro Scltl,rurc tu sortcr' .ooFnsroon. as F)vrlcd tut l,yS*ron l70O ofth.
<br />tlhor CLic, for rlr p.rfo'mB! of rh. qott for whi.h rh. !.n is issucd.
<br />I h.ve anl wiu minrrin work F Lory{nsali.n in{raNc. is dqtrt.d hySccr$n.l?0ool rhc Llir c(xlc hr rft pcrlorm3n.. of
<br />rlr xtrk li,r which rhi\ p.rnir i! issEl. MyvorlcF con,Fn\d'on insuiamc c.rar axj F)Iry numhcr rc:
<br />S//1t t tN-.:2 N\<,e €uN,\
<br />Lot 4
<br />/,-*o rhdt in thc p.nnrmn!{ ofrhc *ork id whi(h rhtr pcrmrr t i\!r.J. I shrll nor cmPloy nny r{non in 3ny ntanNt
<br />rm suhj..r b rhc mrkc6 drmFnsarion hws ol Crlitumif,. afll aSEc rh{r riI noulr h&om suhr.r brbc
<br />wolt6 conFnsrr i,)n pnrvsnJns ol Setbn l?00olrhc ljbr Gri.,I shxll bnhwiihcomdyw hrh){t'mrnn,ns
<br />WARNINGT Fa,lnrc to scurc workes .ropcn*Loh rovctulc s unl.w,U. anJ +rll suhtcr nn . Pnrylr tr sininal lEftllrs ind'
<br />civ lin.s up lo onc hundBl lhousaftl Joll6 (SI00,UD), ,r rdJilil[ !' rhc ..d of $nPcnsahon, dam3.l il Provrl.,l ttr rh.
<br />Orlc, ur.ad d'l ruomcy's ltcs
<br />? arrLrcr*\l at-eo ezh.!a
<br />I-IC!]NSEI} ('(
<br />':{ RACTO R
<br />DUC|-AR IION
<br />I hcEby rfinn!tu]$ pcMlty.lr--rjuy rtur I r lun{'ltn.rlln)vlsir).oichrnrcrI(co.rnkn(DlwrlSc.ri('!7 r0) orD'vton 1
<br />ol rh.llu{nc$ anJ Pnnc$DrsCulc, aBl my li.cnsc ^ i" tulllaRti cllc(r.
<br />4<58
<br />(
<br />C9IEIAIJEIIIAIEIDINC.dCINCI
<br />Ihcrcbyalltmun,lcrpcnahyorlcrjuryth{llhcrcis(.onnrudi,nknJnSs8cnyntrlhepcrrirMccorrh.w{tklirwhic[rhirFnnirn
<br />issucd (Se. 1017. Cir C )
<br />4!&.!C IIUECLIEAIIoI
<br />I hn$y xliim, rndcr p.trrlryofpcrjlryonc ol rhc ln owtr,3J.clJrrnrs:
<br />Dcm,liru Pcrmih Ash.ros Noldi..ltr,n fc'.lcrnl nclrLrtrff (1 1.4(). Pin6)
<br />Rcq.'nd tr(crol Nohllc i,u
<br />I enirrhar rhc lt'i.rnl rcgul(nrtrs rSriinS !s6c(o\ rcRrrl rrc rcrqr!l(atilc h thn noic.r
<br />0.*Vx:rhir I havc lcrd rhh apd(did.nl il c lhal ih. al$vc iraor rornn i\ oF(l. I rlre l(, conrpl, wirh rll Cny lnd Counly
<br />nlSrnrcli*srclf,ringlobuildinB.onslruda',n,lrxlhc
<br />atDve Bnrionc'lotuFdy lnr inspdi,n p .Fxcs.
<br />Appli..nt or Aglnl si!.{lureK )otz ::t4;
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loorivenVl nsulation
<br />Rool Sheathino
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ivlasonry
<br />Pool Fence
<br />T-Bar
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />Itt
<br />FINAL
<br />Certificate cc n
<br />Notes, Remarks, Etc
<br />-+
<br />BUILDING. INSPECTOR RECORD
<br />Forms/Steel/Holdowns
<br />Handicap Req.
<br />trr .r ! Nfc:-
<br />L rdq \Al,lc\.:-
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