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SITE-WORK DATE tD/stG.COMMENTS I hcrchy rrhnn un,lcr Foalr, ol !.rjury rhd I m ckmfl ln,m rhc CnnrracroF' Lic..sc L.w ltr rhc tullowi,3 rcaYm (S'c 70.t1'5
<br />Bunnc$ !",., Pnncsioo C l.): Any Cily or Counry whth rcquncs , Fanil ro c.n{ru.r' llr.r' imPovc. dcmulirh or rcPan 'nv,
<br />nru.rurc. Ilior (o irl isuan0c, llso rcquircs lhc.lPlica ntr \n.h Irmil to ilc a $sncJ i,rcmnr rhar h. or shc is liucncJ IjuRUa'r.
<br />lr lhe povirions ol rlE Contrluror's !-ic.{'l hw (CIEI'lcr O, Co.ncncn! wirh Sccrnn 70m of Division I ofllE Busituss d
<br />Pnn.s\n'N Cod.) or lh.r lE or sh. is crcmfl rhcrcfmm a!,i rh. br$ lnt lh. alLged .rcmPthn. An, vnrhuon ot Serbn r0.l I 5 bv tnv
<br />xltlic, n)r.lcmnrslbjeckth..ppli.anlk,a.ivrl!.nalryor.otmorerhdfivchun!rc,ldoller($500)
<br />A4atr ow$ or rhc pmrdr, or ny .nployccs * h wrs.s as rh.n sb Nnlcnrain,n. qill do rfu v$k drl rhc srfrrN is tur
<br />dr.frLil or o,Icrc'l ttr sh (se.7044, Busim* &d Ptur.*ion. Cds T hc Cdnlr..nxi l-ien* bw dNs not a{'plv b an owmt of
<br />rhc pmpcdy wk, bnius o, iqmwr rhcon..nj wrn) J,rcs skh kfi hrmscllor hcrcllo. rhn,ufh hF or hcrown caPlovccs,
<br />|rn,,id;,i rhd .kh ihpruvcmtrls m fr, i .nlol or oilcrctl lnr salc lt h)srct. lhc h( 'ling or in{'rorcmnr i s'n wnhin Drc }ttr
<br />;r conplcli,'. rhco*;rBu ddwi harc llE ltJen.llovinC rhll lE or rh. Jrr d huill o. inqtov. rh. ProlElv f{{ rhc noQoe ol
<br />,. !s .*ncr oI rhc ,,sNn y, sN ex.lusiv.ly co rachns with li.ctr*J conk&r1,6 b .onntud rh. Pr)Fcl (Scc 7044 Burms
<br />rnl h.f.\\.nC(klc-lhcC.ntacrorsLrccn*LawJltsfr dpPlyroanowncroltrol'crlvwhob,rldrorrmFovcsrhcr'on.
<br />.tri who onkacrs tur $rch pntct w h a Conkdcn)(s) lircnscJ pursuMr !' rhc ci,nta.ttr's t-lcns lj* )
<br />u.dft Seln,n-. A &P
<br />. l-/J'- )-o
<br />PECIAEAIION
<br />I hcrchy a0nm uhd.r lEo.lly ot If,dury otu or lhe following d.cl,r{ions:
<br />-I
<br />lravc.nl will roinrah t C.ttilic.ic olconse b S.lf_lnsurc l[ u*c(' conFnsrtion ss pturid.d lor bv Secrion l7m or rh'
<br />Lt or Cod.. ior inc pcrfotu. of lhc mrt for *hicn !n. pdn rs issuc!
<br />-l hav. .nd sill nainr,in workcs comFnsarion irsur.Nc. &r rcquicd by Sel n r 1700 ol rhc Llbor CoJ.. nrr fi' F rbmucc of
<br />ilE srk lbr whih rh6 r.rmir is ilsu.n M, wor*cn urmpcnerion nsutec osicr,nd rdltv nlmt4r @:
<br />@d,ry rhd in rhc pc nmrtu. of rhc work tbr *hrh rhi\ n rm is ksucJ. I nrllnol crylov anv p.so. i. anv tunmr
<br />$ s ro h.!om shjcd b ihc wo crs q,ol.nsaron ldws ol Calibrni{ and l8rcc lhai ii I should Lc.om slbJcd ro rh'
<br />worlcG.{hpcn!,rtr)dpbvisionsofS&rionl?LxJofthcLaborCul..Ishitltndh{i$conPlvqithlhoeF)v6'ons
<br />WARNINGT i{turc nr Bsc wotkcs'.omFnsarion (.vc.,e. F unhwlnl atu] \h l slbje.r ro mplov.r lo ditrinal ItM[Es lnl
<br />c'en irr\ trD b.& hun'imJ rlbusu dollar (!l{Yy.-z.k^,***,-y:"'^.-*"**S&rtrm l07a ol lhc LrhtrCol., dcrslaDJ i otrry
<br />l-tcDNst:D ( ()NTR,\cloR
<br />DI:(]I,ARATION
<br />I hcrhyrtltrnundcr F-nalryolpcrjurylh l ao l'(.nQl undcr Pnrvsion of ChaPl.r I (Nmmncrn! w,lh Sc.lPn 7ff1) rDlvtrir)n t
<br />ol ih. Uusdcss dnJ Pmlc$ionsCodc. d fty|ccn* i\ in lull lt*cc {rlcllccr
<br />Li.cnse Cl.ssr-Liunsc Nrnb.r
<br />D61€:- Conlmcto.
<br />-
<br />CAISIBUCIIO!.IIIDINiAGINI:I
<br />I h.rchyrflumtrndcr lcnrlryol !.rjury rhrl lhcrc isrq,n{tucri(,n L ing!!.ncyforrhclctJtrmmccotrhcuorklo.wlr'chrhir|}crmiris
<br />hsucd (Scc :1097, crv C.).
<br />bnJcr'r AJLlr.sr.
<br />APILICANT I'FCLARATION
<br />I hdrly ,ltinn undcr pcnllty ol pcrjuy onc oI lhc l'olbwins dcunl ions:
<br />DcBririon P.rnirrAshcskx N.ril,c.lio. FcJcEl Rc-s!L! ions lTnb 'rc, Pan6)
<br />_R.qur.d Lllcrol Nrilicdon
<br />I ucdfy rhar rhc rcJcrllrcsubrniN ft'8,rdiIr8 rst'cnos r.B,!.ldc nol ll,tlli..hlc 6 lnls F iccl
<br />44{niryrl-t I h,"c rc rhis lmlicxt ()n ihJ starc rhar rh. atx,vc inrorn i,tr kroftcr Iasncbo,mplvwirhallcirva counrv
<br />"nnnn"c\ rni surcIf,q\ rcLrDs r! bu Jtrr(!qtu(|tr.n.rnlhrrchvJurlxryqRP.qnrcrtrc\orrhsctrt.n,la.un'yrucirdUFDrh.
<br />Jhrc mnlii,nc,r ntuF.dy rir ^i,.-.*&/ l-r' ,/-/
<br />ApD,ic. or^penrshm,orc Y K4"0(t 4*;. thta ' t 'tJ/- 20
<br />r"^t***,oa,r,.Vt. (tGoB€ A7'tt C. l'LLtz-
<br />Forms/Steeli Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/VenVl nsu lation
<br />Rool Sheathino
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL r /zJ/ )a2a Pl;fasl
<br />Cert it i catezabaan6a n c y
<br />Notes, Remarks, Etc
<br />-.+
<br />BUILDING. INSPECTOR RECORD
<br />Set Backs
<br />,-,,.. t- tJ-att
<br />I =
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