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SITE-WORK DATE COMMENTS OWNER BUILDER DEI,CARATX)N
<br />I h.rcby rlllr lnd ltnrlry or pcrjurt th,r I m cr.nfl rmmrh. Coftd.ld\'Lic.trs lju rbr thc lollowir8 rcnv,n (Scc70:ll5
<br />Busnrss ! l Prolassotr Codc) Atry Cily or Counly whi.h rcquncl 0 Jlcrnil kr (nFlrud. ltrcr, ifrprcvc, dc nnnh or rpatr My
<br />(rudur, I'hrro ils is\xtrsc. aho rcquiE\ rhcapplicanl ir suchl)ermirt' filca \tn.d {rt nf,nr rhd hcor$r h liccn$d ,unusnt
<br />ro rh. p6v,sk x or'tr Co krcro.s LicctrsBl bw (ChrDrcr 9. C.nnncncinA wilh Sccri.n TOOO of Division .l ofrr* Bu\i.c\s rnd
<br />Pnt$ions Codc) or rhd hcorshc ncrcnrfl ihcrcfroflotrd rhc h.sis nnrhcallc8cd cicmprion Any vn,hrionorsc.lion 70r15 hrnny
<br />lpplicanr fu!pcrnir suhjal\rhc applictrnrb0civilpcnllryofnotBtrdhdnfivchu.dr.ddollrsl$5m)
<br />I.* utrm.Drrhcpn,tf,ny.ormychpbyccr*irhw,C.\.\rh.ne'k.onrr.nsarion.$illdolhce( ornllEnnllEi\
<br />inr.ndcd oroficrcd for solc (Sa ?G1,1. Businc$ ud Pmic$ions Codc l hc Contracrr\ l-iccn* L!* docs nor q'dy ro M ownn ol
<br />rh.pmFny $ho huikls or inrrfl)vd. rhcd,n. aid who dms such sorl himsclfor hfslfo hmugh his or hcr own cmpl{,yces.
<br />pmvidcd lh(l such mlrmwmnh arc nor irrcMct or otcNl for sih.li ho*crcr. th. huildiq or inlpmrcEni i\sldwirhin,'m Jrr
<br />of.onpLrion. thc O{nd Auitn uill hatr rhc bunlcn ol pn*ing rhd lE or sh, did tror buikl or in{mvc lhc Jiml,.ny f{n rhc puryrt of
<br />-lh$c
<br />dNillnEinllinrCcnificrreolConscnrroScllrlnsurclor*orkcs.r,Bpcis n,n,a\ptuviitdrdbysc{li{)nrTtuollhc
<br />Irtxn Cod.. for rrf, pcrfornrncc oIIh. so* lor which lhc psmir is is\ucd
<br />lhrrcrnd*illnrrinrrio*orkcr\'co'nnn\rrininsuRmc.Ar.qdtudhtSLrtn :lTlD.frhcltrbo!Codc.,orrircprrionrnnucol
<br />Myworkc^ .o f,.n\dion i {rri.ccatricr. poli.y numh.r nrc:
<br />lrhqeD
<br />-l
<br />ccnilylhlr in rhcFnbrmtrnccofrhc qqk lor which rhis pcrmir i\ isucd.I sh ll or c'nploy .n! P.Fon in ony nrmrcr
<br />$ r( h tr.or subi.l b rhc works .otrrp.trr on lnss or Clliromir. ind r8rcc thor ii I should h.conrc shirr ro rlr
<br />wolkcs.on$nsarion,'rovhhnsofScctionlT0ooflhcL,txtrCode.l\h,ll.tunh,irhcon,llywirh'ho{Frvirions
<br />WARNINC, Fiilurc t, scurc *orkc^ on1P.n\arion .ovrrage is xrlrwful, ,nd shrll subrc.t an en!,nryfr ro rinilo| penalits od
<br />.i!il lnu n|] n, on. huRlrcl rhou\d (l ,loll ($|{D.(XX)). in iddiridr t) rhc cosr ol con{cnsalnnr. Jrmagcs r\ pft,vidcJ in rhc
<br />l.xhtr (irl.. rc,.! xorl ((
<br />l,t.(L\R\lx)\
<br />I h.rohy,ffinnundf p.MllyofFljury lhar I rm lianst undcr rmvisiqin Chiprcr 9 (comEn.in! wnh sccrbd 7u l oroivnmr l
<br />ol lhe Bu\ircssand Pmfcsi,'ns C.d..,nd my lk..\c i\ i. liill fde ud cffNr.
<br />onk.,5
<br />I
<br />lalI-lxllclla)-llrulllqrr!,I1I(r
<br />I hcrchy rftn undcr p!trrlrtolpcrlory rhrrrhcrc i\ r dnnrddi,n Lndirt rscDcy lor Ihc Nn'onMrcc.ihc wotk li'r *hich rhi\ p.nnir is
<br />isrucdlS.c. :1097. Civ. C.)
<br />l.cnifyrhrrrh.fdJrrrltugul,ion\rc.etrding.shc\losrc.rovilrrc,rorrpplicrhlchrhtpnjccr
<br />rtr"',$:ily Ihli I luvc mtul rhir omlicatnnr lxlsrorc rhrr rhc $ovc innrnuri,,n isc.ner I rgm ro coortrl! wirh rllCilyrndCounly
<br />rlxrc rrnri(n{J rmp.ny tur i'n
<br />'1ppli,trtrl orn[$l SiRnxttrrr
<br />horDr rcFr\rnrd ihs ofr;:'u;[js'.
<br />Set Backs
<br />.r&"f)
<br />UFER Ground /l
<br />SLAB Floor
<br />Subf loor/Vent/l nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lVlasonry
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />I
<br />FINAL Y/>z /// .r+fl
<br />Certiricate ol Occu n
<br />Notqs, Bemarks, Etc
<br />,11/
<br />BUILDING- INSPECTOR RECORD
<br />ID/SIG.
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />Pool Fence
<br />-1.
<br />as owncrolthc nropcny.0mcxclusivclycotrrr$rin8 wirh liccnscd conrruckn\ h.oinnd thc nrojcd (sN.7().]4. Bu\i"c$
<br />kt Pf.fssbtr Cod. Th.ConracrofsLi.cns.l-awdoc\n.rtrpplybrnowrcrolI'()|xnyvhobuildsornnprovcsrhcrcon.
<br />rnd who contrids for \uch lroFls sirh a Conra.r.(s) liccnscd pr{urnr ro rhc C<,nrr.ror\ Lkctr{ tiw)
<br />I nmcxcmrrundq Sccrn,n ,a & PC.larihi\ toN)n.
<br />I)ure ()EnPr
<br />lIAl(D&l-C0lilt[NSAIIA!
<br />DICI,I.BAIION
<br />I hcrc6y riliirnundcr pcnalry olpcrjrryotu ofrhc r.ll.wi,rs dc.luari(,ns:
<br />L.nJcir Addrc$:
<br />-
<br />AITLICANLDD!:I.AXAITON
<br />ItEEhylninnundcrpcnlhyolFljoryoncolrhct llowi"sdcclurn,n\:
<br />D.n,lilion Pc nits.Ash.stos Norilicaln'n Fcdcr!l RcEuhln'ns ('lillc40. Pln6)
<br />Rcqutcd L.rrer of Nolilulion
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