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SITE-WORK DATE IDiSIG.COMMENTS OWNIiR AUILDER DEI,CARATrcN
<br />I hrrchr rrfirto uidri p.tr,lry orrcrjury lhnl I am cxcmB In)nr lhc Cotrkr.ttra Li.ctrrc Lrtr ior lhc tollowi4 rciv (sc..70:11.1
<br />Bosinc\\ M Pi(nassn Codc): Any Cily or Counly *hich tqrn.s , lEnnil ro conslrucr. llrcr. i6p!,v., dcnmlGh or rcnair a-ny
<br />{tu.rurc. pridtu ns issudncc. ako rcquircs rh. applicrni r.r \u.n Fnnn I. filcn sisncd {ar.mnr rh,r h.or shc ir lic.nscd Purustrr
<br />ro rhc ptr,vi\i{nr\ of rhc (in ra.rors l-i.cn{d tiw (Chrnlcr 9. (i,mmcn.ii! *irh scdior 70lo o, l)ivhn n I or rhc Busincss otrd
<br />Pn,fcson\ C!d.) orrh.r hc or shc i cxc'npr rhcrcfn,m lnd rhc busit for thc rllqcd cxcrPrion Ant vidriionofScctilr?0115 hy rny
<br />applica n,opcrmirsdbrc.r\rh.rrpli.anrror.ivilI'cnalryol.orrRtrcrhilirchutrdrcddoll.r(55m)
<br />l. a\ .wtr.r of thc proF y. or nry cuuloycc\ wirh srgcs .\ ihc'r sl. mmncns$ion. *ill do rhe work aM 6c sBlrc is nor
<br />i .Mcd orontrcd thr slc (sm 7044. atsnrs and Profcsio.s Codc: lhc Qrftacttr s tj.cn* tjs d.cs nollPlly tt ri.Rmr or
<br />rlr pR)lrny who bxilds or nnl)mEs rieF)n. ud who docs snch $r'rl{ him\cl, or lErell or rhR)u8h his or hcr own cmpbyccs.
<br />providcd rhar ch impnrMinrsenn inrcndcd.r.r.Ed ln sxh ll k,w.tr. rhrtdiklin8.r irq,mvc'mnr k ekl *nhir onc }!lr
<br />o!conphri(nr ihc Owtur Build.rBill h.vc fic hrrdcn ol fovin3 rhrr tcorlhcdid tr huild or inprevc rtu nmldy ior rhc Puqn{ of
<br />ltl
<br />illlr. rr u{ rcr , r rh. rr 'Il.d, rm ct( lu\ r c l} conrrd 'ns *irh liccnscd .o k{hs ro cotrllfl.l rhc Pn,Fcr (s.. 70t'{. Businc$
<br />SslJ \f\nlsen Lhdc rhcC.nrrJcroir t trcn\. Lxu J',cs n rrlflrto ano*o( orI(,r^- ywho huild\or imFoles rhcrco.,
<br />lnd *ho mntkG n, such l)rcjsrs wilh r Gnnndo(s) liccn , ^und rirhcGlrrr rrtr sl.i.cn$ lnw)
<br />,,*"x
<br />ilrlt]llltM
<br />I hcrcby illirrundcr pc.llly ot p.rjlry om orrhc rolbRin! do.lmrions
<br />I hnvc xlwillnui rinnCcnificrtorC.n\crt,SclalNurclinworkcr'compctrsdn,n,N[ovd.dl'orbySccrn,n.]7molrh.
<br />l-ahr Cod., nJr rhc p.rfornrmc of lhc wnrk lor $hth rlf ldnlir i\ itlucd
<br />-l hnvc 0trd will mlinr,in $orkcr' .urD.n$r ion iNUnNc. .s rcquircd hy s..r i.tr r7m .f rhc L.lxtr Codc r(r rlt p$LrnENc oi
<br />lhu $ork lbr which rhisncnnir is hsu.rl. Mywotkcn compcn\arion insurnmcorid md lolicy numhcr m:
<br />ffi**,ul*r,,:,rrt
<br />n.coirhr*o fr shi.h rh'( |Ennir ir i\$cd. I \hrll nor rnln.y rny Nr {r rn,fri.'
<br />'.rk.ri .o.Ensridr h*s ol'Crlir'orni3- rnd asrc. rhd if I rhould hccoM \uhj..r rorlt
<br />shrll. n)nhsirh cotrl|rly $iih rhxc pn)lisi(r$\ (fsc.nri l7(x)., rh. Lfitr ( rtr
<br />*orkcB .onrcn\d n corrr Ft cmtloFr lo sininrl pcMllics dnd
<br />ion. datrugcs u\ pbvid.d for thc.iv,l iircs uD lo orc hundr.d thoDund doll \ ($100.{XD). irr
<br />:::uffiT[,l i'r.r.{ rnd 11(rtr.! \ lt.\
<br />(
<br />I hcEhyalt !trdcr n trrlryorlcrjoryrhrr I Mr li.cnql p.ori\ionof Chrrrcr I(connNNing $irh Sccrion 7UX,olOivi\i 3
<br />ol rhc Busincss d ftofcssionsCodc. anJ my li..No h in hrll li'kr md cl lNi
<br />CONS RUCNoN LFNDIN(] AGENCY
<br />I hcrcby lfrinn undcr Fnollyotp€rjrry rhai rh.rc L\ | snsrtuctiotr lcndins aseicy nn rhc pc.fomxncc olrhc work ror whi.hlhh trirnit is
<br />irsrcd (Sc..1097. Civ C.J
<br />AITLTCANLDECI.AM.IIAN
<br />I lfiby.1tim undc.,.nolty of pcrjury onc olrh. lolk,wing delnrntions:
<br />Dcnrniioi P.nnirl^sbcnos Noliicrrion ardcral Rcgohtio.s {Tirlc,lO. PM6)
<br />_Rcquncd krl.r of Norilicolion
<br />/ r."r,rvrr,.r'r,"r".r*, -c,r^
<br />h*L**.1*r,r.r,'"rt
<br />eh,vc nr rio cd n'.Fny l inspccr
<br />src ullir. tror rpt, i.$lc t, rlri' P(+cr
<br />crh3rrhr rhrr i'rtu' rliI i\cotrccr I ngi.! I
<br />""*U* *.",rn.r, X=
<br />oomtl, wnh lllCir, rnd Cou.ry
<br />::':iJ;],ly
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Rool Sheathino
<br />Shear Wall
<br />Framing
<br />lnsu lation/Energy
<br />Drywall
<br />Brown Coat
<br />It/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL flKlts fi '/itvqtu//:74)vvCertilicate ol Occupancy
<br />Notes, Remarks, Etc
<br />BUILDING. INSPECTOB RECORD
<br />UFER Ground
<br />Subf loor/VenVlnsulation
<br />Ext./lnt. Lath
<br />r:4
<br />Y
<br />Liccnsc Chsr
<br />-Licd*
<br />Numttr
<br />D.l. l-onrnctor
<br />ADDlirnnl or ,\x$l Si,tn ltr.r
<br />t4l
<br />tt
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