|
SITE.WORK DATE ID/SIG.COMMENTS OWNER BUTI,DER DELC RATION
<br />I hcrchylllr undn !.ntrky of pcrjury lhar Idcrcnpr rrco rh. Contr.ros Li.cn* tjw ror rhc rbllowins r.asn (S(?01r.5
<br />Btr\ioc$ !,rd Pmie$ion Code) Any Ciry or Cortrly which rcqnircs a Frmir ro consrrucl- altcr. improvc. d.moli$ ^r rcrsn any
<br />eru.rur., prktr b ns hsuan.c. al$ equtcr rhe appli(, nx su.i pcrmir t, fih r sisftd {mcrunr rh.r h. or shi is licnscd pusu t
<br />lo lhe !rcvisions ol tn Conlmctols Liccnkd Lnw (Cllapl$ 9. ConhrmirS wirh Scclion ?OO0 oi Division I or rht Bu\inds aid
<br />Pmfcssions Codc) or lhnt lf, or shc h excmpl lh.rcrrom nnd tu bash lbr rhc allc3cd cxcmplior. Any violnrionorSNri,!?0,115 h!ant
<br />aprlicnnl for a riLrnril su6r,{ls lhc lpplicaot lo acivilpc.altyotnot mrcllBn fivc hundrcnd ll&s{S5Oo)
<br />-1.
<br />!s oqncr otrhc !m!.ny. or my cnrrLrrcs wilh auScs N rl[n soh conrpcns.rion. ailldo lhc wolt oi rhc srMiu. i not
<br />inrcndcd or orlcrerl lor qlc (S( 7(M4, Bu\incss ana Prolcssn,ns Codc: Tle Conrnctn s l-icdns. tl* d*r mr ardy ro r.owncr ol
<br />lhc F)ff,ny wb builds.r irqhvs rh.Mn. arld wh. ddsskhwo* hims.l,.r h.s.lro.thmuSh his or hcr oqn cmpbyccs.
<br />Frolidcd rharskh i'npmlcnrft@norinrcndelorollercdlorsh.llhow.Er.lhcbuitli'ls.ri(roEnEnli\sllwirhinnrc)tr
<br />ol complerion. lhc oqnc. Buildq will hlvc rhc hrdcn of pnviry rhlr h. or shc d il ret huild o! irq,mrc lhc rmpcny for rnc puryr{ ot
<br />-l-
<br />aso*ncroflhcprol).ny. !ncxclusivelyconlru.lins{irh liccnsed conirocron ro con(rucl rhc pmjccr ls.c To,r4. Bu\inr\r
<br />Et)fssbn Cod.: Th. Co.kictor's Liccnsc Law do.s nor apply b mown.r ofprulcdy sho huilds or nnprovcs rncron.
<br />rtrd sho.o mch f{r slch proF.a wirhrContrcb(n lic.nscdpr\uanr t'rhcci)ntrcttr s Lien$ tjw)
<br />q
<br />IIEELABAIIOX
<br />I hcrcl,y rllnnrundcr lEnalry oi0crjuryom olihc iolbqnrS dc.lurrions:
<br />-l
<br />h,vc ad will mirrain a Ccni,ic.t. of Conscnl '. sclr.l$urc ror workcs conll,cnsarion, os pmlidcd lor bySecrionl?0Oorrhc
<br />hhor aodc. for rhc,xrfonDncc oIrhc wolk for whi.h rhr pdmir k isn.d.
<br />-lhrlc
<br />and willnainrain qorkcNr compcnsarion insuruncc. !s requncdbySccrioi.lTfi)olihel-ahorCod..totrhclrlf.flMnccol
<br />rh. *1trk litr whth thn pcnnil i! h\En My uortcn o'nFnsil ion insurlncc caricr u rDlic,numb.r,c:
<br />I(nifyrhrr inrhe pcrforromc {,irh. *ork for *hich rhi\ !.rnrir is issucJ. I \hrll nor cnlnloy rny P.r" h.flynunNr
<br />s Nbhc.onr subj$r tu rhc *o*$J .onrlrnsrrion h*\orCdl,lnnrir. Jtrd d8torrhrril I lbuld tNom {rh]l-n n)lhc
<br />workcrs..rnpctrsarmrpnrvkionsolSNtiotrlT0OofthctrhtrC.dc.ld$ll.hnhwir[.onDlysirhrho*F.vi\i{,rs
<br />W,tRNIN(;: rrihrc t' {cuE workcA conDcnsrii(,, covcrlgc r\ urLwlul. anJ \hxll sohjcrr 1cild.ycr t,.rimirrl Ftrrhics ind
<br />.,vil fir.suthonchrndrcdrhoxsaiddollnrs(51(Xl,(n0.inrddln,ibrtuoq.f.o Nns.ri.n. d nrrcs rs fov]dcd lor rhc
<br />S..rion 10T6 orrh.latbr Cod|nrm{ i l
<br />'.,",- q fzo /r y
<br />^
<br />t)t( t.\R \ lr{}\
<br />I hcrhy ufitmundcr pcnrllyotpcljuylhal I a liccnedundcrrrovhiotrofChaprcrI(conrmeinswirhSccrion700()orDivitnrn.l
<br />ol thc Busircs alld Pmtc$iorN Codc. orn nry licensc ,s r full fore atr,l cll(l
<br />CONEIruEUOII.INDINC-AOENCI
<br />IhcEhylinmundcr!cn!lryofpcljuryrharrhcrch0con\rn,criorlundin!r8.ncylorlh.rsnnBnccolrhcsorklarshichrhisNirniri\
<br />isrucd (s$ .1097. civ c ).
<br />ATILIIANIDECI.AAAII!,IN
<br />I h.,rhy afimr undcr pcnolr, of pcrrury orc ofrhc tullo*inB dcclnrurions:
<br />Dcnnlirion Pcrnrils-Astrnos Notificalion FcdcmlRcBul ions (Titlc 40. P.n6r
<br />_Rcqutcd txttcr of NolifE.rbtr
<br />-l.cnilirh
<br />thc fcdcEl re3lllrion\ Esudin8 lshcsros lcnDvularc nor lpnlic$L io rhn Prcjc.r
<br />I c.n iry rhd I h,vc EM rht ,mlt{lion atld $0r. thar rhc rh,v. inrormtrion i\ cotrcd I lBre ro complt wil h lll Cit ! nd Cnu y
<br />!rditun.(\ n rlSlrrc I xnl rcl li b huildnig cointurri{,,. rfrlturrhynurhtrir. r.IirL{nnrnN olrh( Ci! ntrd Coulllyn) cnrcr trIron rhc
<br />h,tc trttrri{,ul fmNdy ilr qLale
<br />ltLL*
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Rool Sheathing
<br />Shear Wall
<br />Framing
<br />lnsulation/Energy
<br />Drywall
<br />Brown Coat
<br />lt/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />En gineer Final Report
<br />Flood Zone Certif
<br />FINAL tiltll / f/AMilfu .R>Z
<br />Certif icate ol Occu pancy
<br />Noles, Remarks , Etc
<br />BUILDING- INSPECTOR RECOHD
<br />Ext.i lnt. Lath
<br />,*", -Q o
<br />l'emrilc. nnnre (prinl)r I
<br />f ---T------
<br />tt
|