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SITE.WORK DATE ID/SIG.COMMENTS OWNER AUII,DI'R T}TJ!-CAlrATIoN
<br />I hclcby alfim under penllry ol pcrjury rhd I d crcnpr rnnn rh. On racro Liccnsc l-a* fitr rh. rollnwin8 rca$n ls(.7rlll.5
<br />Busincs r l Pn,,csion Codc)r Any cny o. Coutrry whi.h rcqutes ! pcnnir r, Nnrru.r. rllcr. imProvc. dcmltn ot rcprn any
<br />srrucrur.. pra'r b irs i$urtrcc- rho rcquncs rk- Epdicunt (tr \!chp.mirro filc0 sietrcd slarcmnl rhar hcotsh. x licc,rscd pursun
<br />h rh. ptuvhtuns .rrh. Cotrracrols Liccnscd Llw (Ch.flc! 9. Commmitrg wirh s..ri.n ?o(D or Division I or rh. Busi,rc\s a.d
<br />Pofcs\ions Codcl or rh.l hcor sh. iscrcmpr I hcrcl'rofl and Ihe haris r{t rh.rllcscd cxcnDtion. Any vt'larion.fSc.lion703l5 b} lny
<br />lflli.anr for a pcrnit suhjccrsrhc spplicnnr ro aciviltriilry.rmrnn'rclh{n fi'e hundEd dolln( ($5m).
<br />-l-0ro*ncroflhcpn,lenr..rnly.npbrrcs*nhw,ecsrsrhctslcconrpcn\ilion.silldorh.worknturhcnru.iureisn.rinr.ndcd orofr.rlt r.r $1. (S( 1(}1,1. Busirc$rnd t\.fcs\i,ns Ctxl. lhcConmcr.isl-iccnscl-a*docsnornpDlyl.0nn$ncrol'
<br />rhc Imncny who huildr.r i'nlr.ks tlEN.. axl sho des s$h solt hin\clfur hcrsc!fo! thR,ugh his or h.r osi cmpl.yccs.
<br />polrdcd rh ruch in,proEnrnh rc ft, inrc L{ or dTdd for $h ll hoscrtr. rh. huildi'rP or inl](n rmnl is sh sihin nnc lttr
<br />ol.onDLri,.. rlt O*ncr AuiHcr sillhlw thc turdcnolpmvins lh0l h. or \hc dil ml huikl or iqrorc lh. Pmp.ny f{n rhc Pnqx,{ of
<br />l. u\dwndorrhc!n)pcn!. smcx.l$ivelyc.ntro.rir8 wirh lic.h\.d.onractor ro con(rucr rh. rmjccr (sN 7l)'|l, Buqncss
<br />n.d lhrlLasi,tr Code thcConta.ttrsLic..schwdo.\n.rlmlylo!nounErotpfl,l.iryqhobuildsornnprovc\rhcro..
<br />rtrd wh..onh.alor ch pmFlls uirh ! Conrrdo(s) liccn\ed !trrurnr b rh. Conirudols Liccnt L!w)
<br />I .n cxcmor udcr Sccl ioo-. 8. & P C for rhis rcrwr.
<br />DrI€: Oen..
<br />W(IRKFRS' (I)ItIPENSA IION
<br />DECLABAIIIIN
<br />I h.Eby.lfirmundcr pcnallyofpcrju'l oi. of rlt lnlbwinE dNhrjriors:
<br />Itrlior Codc. liir thc |E i(fluNc olrtu rork lar shi(h rhr If,'trnr is i\nnl
<br />Ihovca.dwillmanrhhsorkcKc.n{.nsriiotri'sur.f.c.r\rcquircdhySalion:17fi)ofrhcljtxtrCodc.lorlhcp.rnnrnc.of
<br />thc wort iorNhichlhn pemir is iss!.i. Mye.rk.B emp.trsrtiotr irsurnrcc cr cr akl rolic, nun\b.r me:&t+ \rrlrancc Sewtcc- \nci.rB4ro"i\\Oft\8 ?L[ ..n,..,tq
<br />l..nilirl in rh. Nrf.rDrtre ollhc work for shich rhi\ Icrn,ir ir is{ucd. IdxrllnolcD,rloy atry l.rnnr i
<br />$ Nro hcconE ruhtsl ro rhc *1rkcr co'nncisari(,n laws otCrllli,nri( Md laruc rhrr ifl \tu,uld hcc.trf, {rhjcd ro rh.
<br />sn*cr\ conrlEn\lrio lrovki,)ns of Sccrnr]7m ofrht t-rtxr Codc.l \hll. fonh*irh c.nIny qrih rlr\c prcvisions
<br />\YARNIN(;: Frilurc k, *.rc Lv.rkcr snnEnrorio,, covcrrlr i\ unhsful. .nd shtll suhjdl rn cfink,,cr t) clnniD l Fiullic\ a
<br />.ir'l ll r\ rD b orc hutrdrc lMn\an,l dol['\ rSllx).(xx)). n, rd(l(i r,dr rg!\ N fr.\i,|.(l ntr nrc
<br />",,", t-olaultglr
<br />I hcrchy alnD udd.' r.nrhyorpcrjuy rhlll I am liccnBl nnrrn.irg *irhS(ri 7lXro)ol I)nr\lotr:l
<br />-lo Llq tq "e)*,., (-!\A&lW
<br />I hsrby afirn nndcr p.nnlry oitcrjurythlt lhsc h o con(tucr
<br />nsucd (Sec 309'7. Civ C )
<br />)frhr {orI litr rhrh rh]\ Ennlr i\
<br />AIIIICAN[DECITI&AIIQN
<br />llmbyalli xndf Fn,lry oll].rjry onc olrhc tullo*in-s dcclutnntr
<br />Dcnmlirion Pern,irr Ash. o\ Noii6.rrion atdcr l Rc3ulllioN IrilE.rlr, P.'n6)
<br />RcqDtrd I c,(crotNor'liuri(nl
<br />-l
<br />ccnilyrhsr rh. r.dcrrl rclxhrnrns rc! ding .sh.nos rcnmvil irc nor lpli.$lc ro lht!r+cl
<br />l..nily rh l hrir r.ad rhn lprlic xhrr i'ilitrihft s.oirc.r I )grr kr!o !nl trirh 0ll Ciry rn,! crutrry
<br />oili'rxdc.\ rid Sfurc Ln$r nlal ilu xl R.p'cs.nrrrivc\ ol rhi\ Ciry ntri ( dDrv b rtrrrr tr|xm rlt
<br />rtx,vc nEnri{nrd pmt.dy for ms
<br />ADpli..nl or Agenl SiBn.ltre
<br />P€m e nome (prini)r
<br />l
<br />^,", Lll4ts
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Subf looriVenVlnsulation
<br />Roof Sheathinq
<br />Shear Wall
<br />Framinq
<br />lns u lation/En erq y alt lti TN[ts)
<br />Drywall t
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lt/laso n ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL <Llllt9 ttf,-zA)
<br />Certilicate of Occupancy
<br />Noles, Remarks, Elc
<br />BUILDING. INSPECTOR RECORD
<br />q
<br />of rhc Businc$rrd Prolcsion\C.d.. rxl rt li.ri{ n ir lull f cc ulcilicl
<br />lctr,lc' .
<br />^J.l'r.\
<br />UFER Ground
<br />Flood Zone Certif .
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