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SITE.WORK DATE ID/SIG.COMMENTS OI!N ER I]T'tLT}DR DEt,CARAl'ION
<br />I h.r.by Jrlinn undcr !.nrlrt oi pcrjury rhrr l!m crcnrnr ri.nr rhc (tnrrmnr\ t i.cnsc lns ior rhe hlbwins lcrv)n lsccTl.ll5
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<br />ro rhc pmvnions ufrh. Co td.nn\ Li.cn{d tr'r lch rr 9. Connncd.irE wirh Sccri, T(XX).f Divisiotr I ofrhc Inr\irc$ iDd
<br />Pnlcs\iuN C-.ilc)orthri lror shc is.xcnu rhcrcionritrd rh.lr\( tur rhc Lcldlcxcntrr tryvn'ldn rolS$thn?Oll5hyrny
<br />lprlicafr for i Pcmlr suhlcck lhc !pplica lo acivllpcnrlryotnor nucrhrn Iivc hutrdrcd do[1rs ($5lx))
<br />I.ns own.rolIhc8,n dy..rtriycnrrloy..swnhwrgcs rh.ir {'lc compcn\Innr, *ill d(, rh. srk dri rhc {BtuE ir nvr
<br />icrdcn orolttEd Inr srlc lss.. 7011. au{h*ss.tr'l Pi.lcssn s G)dc: Thc Cotrk.cr.i\ Li.cnrc bw dms n.l rtply lo 3n o$Nr ol
<br />rhcpotf,ny qho htrild\ or nnF,vc\ rh.tu\,n. nkl wh. dms su.h {o* hnnr.ll or hcsdlf.r rhn,uEh hh or h.r.qncnrployc.s.
<br />Pn)!id.dthnr\khimrmknrnhrE,i c.ddoroftrdtur\aLlllhor8.r.rhchoiklin8orinlPrctnrntis!,kl*irhir.trc)tr
<br />orconvbrn,n. rlE owrr Buitls *ill harc lhc hurdcn ol pnvir8 nd tr or shc d n, t uiu oi i,ntrott lhc pNrrny f.r ihc Plrlh$ or
<br />l. r\ owmr ol rhc poncny. rmexclu\ivclyconrrllrirr *ilh 1 tr\cn ortrr.r, 'r n) coNrrucl rhc nrcl.rl ls.c 7lll]l. Btr\iNs
<br />aftl PNfLsbn Codc ]'hcConrh.rr'sLi.ctrsc l-ar d.cx nor lprlyk' sdoq cr.lltrol,{ntwhohuild\ornnpnrrcsrh(con
<br />d wn. conl,Gls lni su.h ptr'rrlr silh ! Corm.ro( \ ) liccnql Durunr h rhc Conlrucrm s l-iccnse Ii*)
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<br />am cxcnrnr undcr Sal ion-, B. & P C l'()r lhis r.rson
<br />Dsle OPner:
<br />l1oa$iallraurrNt rl9!
<br />I'III.dXAIIQB
<br />I hcrrh, Jflirrunncr prrliyolprrlury om of rl[ tull,rirg dc.hriti(lrs
<br />lha\cadrillnEintainrCcdittrrcolCon\corloSclflnsurcltr$orkcB.onDcn\dion.!\F,vidcdf{xbySfttnrn1700ofrh.
<br />ubor ( dc. rbr Ihc pt.lnflurc oi rhc *olt lnr which
<br />'h.
<br />p.nnir is i\\Nl
<br />lhrtc.M qillnrinrrin work$r.onlttr.\tu.tr nr\urrtrcc. \ 'qunrd hySc.rion lTlX)ofrhc trhor (ndc.lorrhc plnornunceol
<br />th. *ork foruhi(h rhi\Fanir is i$ucn My*o.kc6 $nlEns otr rtr\unrf,c.rriicr ndrni.ynuD$cr lrc
<br />\r"9 2 n7o7o e*pi,*. '/ 4- /3
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<br />ccnilyrhJr ir rh. p.rhnnrn.c nilhc *ork lor shichrhi\ t'crnri t is{'cd. I \hrll nor c.rployonyp.ron ii rny iMncr
<br />v, ast, hcm rc \ubjccr t,rhc Norks(roNpcnsrri,,n hwsotCrlii,niJ. rnd ngrucrhrr ifl should bc.otrr subacr rorh.
<br />uorkrF con[cn\]tionImvisio!\olSccrion]Tm.frhctrft,Codc.l!ll'lllnnh{nhco llly qirh rk,* fovkn,ns
<br />WAltNlN(i Failurc b {.urc qtrkch .onrFn\rri(nr .ovrrg. is rtrl wful. rtrd Oull $hlccr .fl cmnlo}rr ro cri inrl F-.n lri! rnl
<br />cirl fitrc\ u| k, otu huidad rhousrtrd doltnr\ l$lfiJ,OX), in, dirn,n ki thc c ( ol compcnsirion. danugcs r\ prcrid.d tu' rhc
<br />s(rtr 1016 01 rl{ I rlxtr (_rilr, i'nc'.n ln 11rr rt \ li.\
<br />X",*-. -,*L
<br />DECLAAAIO!
<br />oi rhc llusirc(s r Pnrisli,,ns Co.lc- rfd n,v liccr\c i\ in lullnr.c!trtlctfccr
<br />N*
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<br />7 t98 o
<br />g- ?-r I ( on,m.,ur i/ . ; ^ 8.^.- l&"a q^*tl
<br />QNEIAIJIIIONIENIUNCAGENCI
<br />ulllrhundcr J[nnlryofpcllryrh! hcrc isr..trsru.1iff lcndir8 iScncy li'r lhc lr.nbnnrffc olrh. sork for qhichlhh |lnn r
<br />n\ucd isc. .1097- Civ C )
<br />aPPt r(:/rNT Dtcl AR n()N
<br />I hctrbyrfll'Dutulcr p.trilri oftr4ury onc ol rh. hlb*i.B dc.ldlrti{rtr
<br />I)tnx)lirrn Pci'ni( A\h(do\ Norifi.rrr FrJctul Rrgullions (Ti1.,10, Pd6)
<br />R.quird L.fl f of N.iili.rti0r
<br />I c.f,ilyrh rhc ldl.rrlrcgrhri,,nic!rnli'rgxshc(o\ rrnniHl rc rrr|]tli.$lu k,rhi! fr.lc.r
<br />l..niSrhar I ha\crcad rhn,ppli.riondd nrrcrhdrh.*x,vc innr'n irn tcoB..l l.B,Nr.comllywilh,llCiry,ndCouity
<br />ordinnnccs aod Sutc l-Iws rclrins r,r h!iunrs cordtucrt,n. dt h.rchy aulx{d. r.p.\cnrdivs oflhk Cny end Countylo cnrd llx)n'lt
<br />ahntc n.nri.nrd nn'Fn) f.r \nccrion nu4gE\
<br />lprnicm,m^Eenrsh*,trm Ca'21-- , Do,r ,-3-13
<br />(n"-n*-..,0nn,,, /,,t.^ t)-.,r4-/z.a\i/1
<br />Set Backs ,A
<br />Forms/Steel/Holdowns 5-&qt
<br />Erection Pads \)
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation t\
<br />Rool Sheathing E-21-w Y.Wbq
<br />Framinq
<br />lnsulation/Energy
<br />Drywall /A
<br />Ext./lnt. Lath YXIX
<br />Brown Coal 6-W-t w"vt0)
<br />l\ilaso n ry U \)
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood {on4 Certil./\
<br />tCAaJ)I/*6,4- 19
<br />FINAL
<br />Certificate ol Occu an
<br />Notes, Rem arhs, Etc..
<br />v
<br />/U
<br />I
<br />I I
<br />BUILDING. INSPECTOR RECORD
<br />Shear Wall
<br />) =-fi
<br />'?^,H
<br />( 'r, z{\t ^DE*-t\--!
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