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SITE-WORK ID/SIG.COMMENTS OWNOR BUIt,DFJR T'EI-CARATION
<br />I hcrchy llftm lndcr pcmlty or p.rjlry rh,r L'n cxrmrr ri(,n rhc Cork.ct,i Liccn{ l,sw f(tr rhc tull,)wirrA rcisoD (Scc.?trll.5
<br />Ausircs rnl Pdasn, Cod.) Aoy Ciiy o. Counry which r(tuir$ r pcnnir k, drnnru.r. ilrcr. nnProrc. dcmolnh or rcPrn 3ny
<br />{rxc(c. prir nr ns isurnc.. rln, rcquncs rlr lpflicrnr lor srh Fnnn tu ik . sisnci n cn..r rhar ht or shc L\ licci{d N^urtrr
<br />ro rhc ,)l,li\iotrs oi rh. contrctoil t,i.cnscd ljw (Chiltcr 9- CommcBin! *irh s.cllun 7(xD of Divisi()n I olllE B,\incs\ rnd
<br />Proicssi(nrsCodc)orrhrr hcorshc hc\cnrfl rhcrefro lnd rhc hr\is f lhc lloSddcxcnrlriotr.Atryvnnnrn,nols(lihT0.ll5bydiy
<br />!pplicanr rbrrrE mirsul,jcchihc rmlicrnr u r .ivil tcnrlry or n.r xtrcrhrtrlivclrndrcddoll$($5lr))
<br />I. as o*nciorrhc ptutEdy. !r nrt cnflorccs *ilh w0S6 $ lhcir sk omp(n\xrion. ailldo rh. *o* dx, tl'. stndm n mr
<br />inrctrden or oficred lor slc (Sa ?04.r. Burin * rid Profcs\n,ns Cdlc: Th. Crn mdois t.tcnsc l-rw docs nor arlly ro rn owncr or
<br />rhc nn)II rt wlh huilds or inprovcs rlENn, oM wh. do.s su.h wn k him\clf.r hc!\clf or rht,lBh hi\ or h* oqn cnDloycc\.
<br />F)vidcd thar su.h inllrow'mnh r. nor imcndcd or offcr.d I(r salc Il hnscv.r. lhc buildirS or imProtcnEnr h $ld *irhi" 'f, ]tr
<br />oaconpLrion. lh. owncr Buildcr $ill hlr rh. hunlcn .l pmvin8 rhli hc or qhc did ,xn boild or inlmtt lhc pmocny ,or rhc purlx,r of
<br />-1.
<br />ns o\rncr ol rlrc Jn)Dcn y. rr cx.lusivcl, ro rrmr i',9 *irh liccNctl ..ntrrttrs ro con\Ncr rhc Pmjccr (S( 7Or4. 3 \in(\
<br />rtol Pnni:\\inCodc'lhcConricktr'sLiccnscLi*docsnollnDlyto0no$ncrolpnp.ny*hobuild\.rinuovcslhocon.
<br />and who c.nrm.r\ Iorxuch pmj$rs wirh a contrcrons ) liccn\.d r r. rh. Contr 0-s Liccn\c lr*)
<br />-l
<br />rrrc\cnr uD(lcr S..rior . B & I'c
<br />D[rLt8trullN
<br />I lrrcby rliirm undf p.nrlry orn rjxry onc ofrhc lnllowirg d.cl rdri.rs
<br />-lh!!cudwillrui
<br />ain!Ccnificrr.otCoi*nrt,sdltlnsur.r.rworkLyJconurnsnlion.$ povidcdli,rhrSccrionlTOroirhc
<br />bli* Qric. rorrhcl)cnornunccoflhc work ao.*hich lhcpennil ir hst.d.
<br />lhrvc rtd sillmrnrrrin *orkcrr cotrPtisrrnr in\!rrncc. r\ rc!!ncd bySc.riqr l7(Xrolrlt l,ihtC{dr. trrh{ PdnrDrr.col
<br />lhc work lnrwhichrhi\ pcnnir is i\\!cd Mywork.'J co r)^..n\rriirr i'sunf... rlcr od Frll., nunh.rnR
<br />-l
<br />ccniryrilr in rhc |xrfortu..c orrh. *or* for whichthis pcirni n hsuc . lshallnor cn,fl,)yany Fs.n in.nyflunrcr
<br />$ as r. trco'tu \ubjc.t k) lhc workcs onpctrernu hwroacllinrmia. and 4rc rhd iil \hould hcconE sl'Fr ro rlt
<br />sulr'\ .,r trtr\nr o t)'!,vr\io N rl s..ri. r.liln)ol 1h. l.xhtr (i . I \l tunhq h coDrrly *iih rh.r niixisn,ns
<br />WARNIN(i Frihrd k, \c.urc vorkcr conrprn{(iotr orcrngc i\ nnla itr cnri oycr ri cri inrl |In ht\ tr d
<br />.ivil fitrc\ ur t, otrc hu|drcd thotrsrtrd doll0r (Sl(x).O0o). io Mdil Dctrsitnn. drnrilcs r\ oridd ntr r[.
<br />S.crnnr 1076 ofrhc tjtxtr Co'lc. idcrc{ lnd ronry s
<br />DECIAXAIION
<br />I h!rchy oinmu crI].nahr.r!.rrur!rh,r I rn liNns.d undn rmvis,otr of Chaptcr 9 ($mrEkiog qnh sccrion 7ur0rolDivhin:l
<br />ol lhc ausincss md l'rsfc$ions Codc. ard my ltcosc t in full ttr c ll cffc.r
<br />caxfff,uuuNrENDac-dliEN{.:x
<br />I hcEhy lnnm undcr lcnaltyofpcrJurr rhd rhdc h r Lvsrru.ri,n hMin8.8ctrcy for lhe Pclrom,n.T orrh work lo. nhich lhis pcrmir is
<br />h{.d (Scc 1097. Civ C ).
<br />AELIAANLDECI./IS{IIAN
<br />I tf,rcb,dlinnundcr pcnnhyolpcrjory on or rhc r(rbwinA dcclr ions
<br />DctrblInr Pcfltri(sAsbr(os Norificrrion Ftdcrul Rcarhnlx ('f irb.r0. PM6)
<br />Rcquied btr(.f NolifE ion
<br />I lcnilyrhli rh.lldcrrlrcSul i(i rrc8 difg \hnos rcnrivrl rrc n.r 'mliuhlc r, rlri( p' ojlrl
<br />-l
<br />c$liiyrhrr I hrlc rcad rhnattli.dl'r url srrc I r l rgr( r).onrdy\ [rllCiryrnd((]unry
<br />ordinlmcsnnd srarc lrss rclding h burldir.e.otr{rcp'csc rrri\r\ ofrhi\ ciry rtrd counly n, rnr.r trFn r)f,
<br />lwc trrnridrcd |(,rcny ihr iD
<br />,\ppli.nnl o./\E.nl SiAmturc v
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />A\,
<br />Roof Sheathinq q-2J1y V.W{tr,)
<br />Shear Wall
<br />Framinq
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlasonry
<br />Pool Fence
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif.
<br />A
<br />FINAL 5"9-lr Y.W;A)
<br />Certilicate of Occupancy u_-/
<br />Notes, Remarks, Etclt
<br />t14-
<br />BUILDING. INSPECTOR HECORD
<br />DATE
<br />Sublloor/Venti I nsulation
<br />T-Bar
<br />kn'lcf { Addr\(
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