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BUTLDING- rilspecron REcoRD <br />COMi,/IENTSSITE-WORK DATE <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Sublloor/VenVlnsulation <br />Roof Sheathin <br />Shear Wall <br />Frami <br />wallD <br />Ext./lnt. Lath <br />Brown Coat <br />IMasonr <br />Pool Fence <br />T-Bar <br />Handic R <br />Final Re rtDeut <br />En ineer Final Re rt <br />Flood Zone Ceftif <br />FINAL <br />Notes Remarks, Etc. <br />{,1\'\fR Bt .t)t.R t)t,l.r nR \ I l()\ <br />l hcrcby !t',irm uhlcr pcnllry {f P.rjury lhd l or dc.Dr rom lhc C.nt,.r.n Ltci* L'w for rhc fouotrins rclsor (s(?rr1l5 <br />Brsincs md Profcssion Codcr Any Ciry or Counry wnich rc+n.s a Fmir b con(dcl. llrcr' impro'c. d'mlrh or rcpnn anv <br />*rucrurc. rior ro irs i$uarcc. lho Equncs lhc olPliclnr lu \u.I pctnri b nh I sisred srarcftfl rhol hcor rh. is licenscd pusu <br />' <br />ro rhr pn;vhions oflhc ConrBclols t-isn\cd tjv (Chaflcr 9, GNmrcins *irh Shrion 7000 or Dilision I or rhc Btr\inc* nnd <br />Profc$ionscode)orlhilhcorshchcremI,lh.r.froNmdlhch\isforlh.lllcgcdcxcmplii,nA.yviola|io..rscclionT(1.]l,5hyany <br />amlicanl tur ! Fcrnrn {rbrccls rhc aprtic rto.civilpcnahy.fmr nDtc rhan fivc hundrcd dolltrs ($500) <br />l. ns ow.cr ot rhc trotEdy. or nry cnrrlotccs I nh was.r * rhc,r alc onn trsrrion will do lh. wor[ srx] rtr slnrlure i\ 'i cndcd d oncBd fo; srE (se.?o{'r. Busims\ rnd Pturcssions Gntc: Thc Conrrncroi{ Liccnsc L'w dirs nol 4plv b !n '$ncr or <br />rhc !$tEdy qho huildr or rForcsrhcfr)n. dqhodoc\$chwd(hnn\clfoihcrcltorlhr'ughhhorherowncnltlovccs' <br />p.';nl.d rh{ su.h istroEmnk m ml inrc' cd oroiT.Nd lirt sk ll hoscEr.llE In'illing or in{mwmnr k $Ll wih 'mvc <br />;l.omplcrion. rh. opn;r Builds willhorc rhc sudcn otrovills llu hc or rhr dd nor hild or nnprolc rtc rslxdv for thc poqr'* or <br />I. asowncrorrh.pmpc.ly- ah.r.lusivciyconrrlcringwnh liccnscd conh.nr k'] con{rucl rhc Pnjccr (S$ 7ur]l' Btr(trcs <br />a,,l E"r6$n Codc ih: Conrracroir Lic.ns. Liw des nol apnly ro atr owncr .r !mp.n v *ho buildr or imlrovcs thcreo!' <br />rtrd qho conrD.t ror such pmrccrs wilh 0 C.nrradonn li.ctrrd puduMr to lhc Co.t,crois Liccn\c bv)' <br />t rmcxcmfl uodcr S.dion-. B & P.C lorrhisrc.son <br />Dot. oRner: <br />wonxrtis crr,nttPnslrrol <br />IIECIASAIIAX <br />I hcrcby !ftn\u.dcr |]cnrlr, or p.tjury om olrh. n,lbwin8 d.chrurn,ns: <br />-l <br />h,vc d*illnmn'raintLtnific corconscnrk'ScltlnsrrcfoitrorkcFcomP.n$rion.a\P'ridcdforbvSNlionlTmorrhc <br />ljtxtr C{xlc,lt,r rl[ pcdhrnrarcc orrhc "ort lor *hich rhc ldnrir h tsucd. <br />lhrvcond{iUnainrrinqorhersc.ml.Noriorinsurrn....\rcquircdhySccrion:l?mofihcktorC'd'forlhc!€r['nDm"l <br />lhc work lor shich rhn ncmir is i$aci. My rqkcr' coml.nsal ion insuBncc m era' FlicvNmbcrml <br />Cu'ricr <br />--R)li.yNtrnrbcr- <br />l.crlrlyrhrr nr ihc t)crlotrrl ,.c ofrhcw..kli)rshi.hrh,\rirniriri..ucd.lslulltror.i.vnnvncronn,nvn''trtrcr <br />s, rs r, h..onk ubjccr lo rhc sorkc6'..nr{n\rri(n lns\ ol Crlihi,iir. rtrd rlr..rl il I lh)ul }f,co'rtsuhlc.r hrhc <br />ro.k.^ rotrrltn\arbn Fruvi\trrF ol Sc crnn,lT(X).irhcLlhrC{xlc. I slnl!. f,fihwnhconDltsirhrhocPmrision\ <br />WARNINO Fnil,trc k, *.u'. *orkc^'c.nDcnsrri(,n cov( s. ir unh*lll. nl 1hrl! {rbj..r m <br />ro o.c hundcd rhous.trd doll \ ($l(Xl.UX)). in lJdirn ro rhe co{ .f comlcns!rMgc\ os providcd i, rhc <br />:: E\l\\U' <br />I hcrchy rl1nlnurdcr pr alryolncrjuryrhd I I'n li.cnqtundcr Fr.visirr.l Chrfrcr 9 (comntNnra wilh S"rion TUXD orDivi\i'tr l <br />ol rhc Busirlcss utrd Prcf.ssiors Code. dxr m, liccnt is nr tull fi,rc n cft(r <br />-Ltctrsc <br />Nr'nhcr <br />s \ <br />!:aNSIEI1:1LUIIBI)INCr!CEN(I <br />Ihcrhyrrltsundcrpcnntryrtpcrjuryrhdr;kr.oi$fldi lcndirB rlcncy rhr ihc pcrfoinrncc otrh. work for ehi.h iht p.nnir i1 <br />is\ucd (Sc..lU)7. Civ C ) <br />Lcndcas Nrmc <br />-_- <br />altlrsANtl)Ecl Earlo! <br />Ihcr$yiftnruodcrptinltyoit rjuryotrc.llhchln,wi'rSdc.l dions: <br />Dcn$lirim Pcnnirs-Asbcsk,s Nolificlrioi tudftll Rcgulariom lTnlc'10. l'xd6r <br />Rc!Dtrcd lxltcr of Norifi cdion <br />I ccniaylhalrhc rcdcrcltcsrhrioN rc8 dins xst dosrumvtlarc or.r|licihlc kr rhi\ ['J'cl <br />l.cniltrhrr I hivc rc rhi.rmli.nx r xRlnrr.rhn rlr irin.,ni ln i\conc.r ligre b co ll]lyLvilhrllCilyrn( <br />ordintrncc\rndshrcLrwsrcldriniiohuildinsconifl.'n'n.a.n :"":"6'_\ilA\M\ <br />I <br />lrndcis Addrcs: <br />- <br />'1 cY.I{r){t <br />lnsulation/Enerqv <br />t?\\c3?- <br />Certiticate of Occupancv