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SITE.WORK DATE ID/SIG.COMMENTS OWNFJR AUILDER OEI-CAN-ATION
<br />I hcrehy afi,m undcr octrrlly of pcrJury rhar I am cxcmnr r'mm thc Gnkdor' l,iccns L.$ lnr rhc r'ollos,in8 rcasn lscc 70.11 5
<br />Brsin.ss and Profcsio. Cnlcr Ant Ciry or C.!nr, which .cqut.\ a Fnnir t, cfln(d.t, 1116, inrrnrt. dcnhli$ ur rcI'rn Jhy
<br />itu.rurc. lJrior r. irs hsu,n... o rcqun*rhc artli.nd lnr \uch ptnnir ro lllc, siSncd srdcmtrr rh h.or she i\ liccnicd nurumr
<br />ro ltc plovhions or llr Cotrtraclor's Licctrred L.w (Chaplcr 9. Co nEncins wilh Sc.lion lo0o ofDivistun I ofrhc Btsinc\s and
<br />Profcrsiotr\C.dc)or rhlr hcor shc iscxemnr rhcrcaro'notu rhcS{sn l.r lh.allc8cdcxcnprion Anyviollri{,nofS..rion70ll.5hy,ny
<br />apolicrnl rd iF.nrn subi.chlhc aptli.an' ro acivilp.nilryorn.r nk'rtriai firc hundod dollais {S50o).
<br />l. !\ o*mr ofrh. lhFny,.r ntt cmrk,),rcs wiihwogcs rhci. sl. conDcnsrrt,n, sill do rlr wo.k dd rh. {Mtrm ( n,t
<br />i' cndcd or oftrcd for elc {S(.?()44. Busincs a Prorcssi.ns C(dc: Thc Cotuacktr'( Liccnsc hv docs nor nmly lo an o*rcr ol'
<br />rhc pn,pcdy who l,oilds or itrFrorcs rhcdn. xnd *ho.les such \qIk hinNcllorhcrclforrhnnchhis or hcr ow. cmplot.d\.
<br />pnvid.d rhrr \trch nqt6vcrnk @ nrn inrc,rdcd or oficrcd ror slc ll lmwcw. rhc hoildirt or inryolcm i\ $ld *irhir otrc ,r.r
<br />olco'nplcri{,n- rhd Owkr Builcr will htrrc rhc burd.nofprcvin8 rhnr hc or slr di'l rn horkt or inprcvc rhc pNtdy aor rhc prrB)r.f
<br />L r\owidofrhc p()|f,ny. rnlcrrltr\irrlr.ofkr.ri',! *ir[ ]ienscd .orrr.t)^ h mn{'r.r rhc pxrj.crisc. Tl}l4. Brsf.$
<br />rnd li,ic\sirCodc: lhc (orrrrlor'\ Liccnsc Lrwd.$ tror rpflyro atros cr ol DioFrrwho huikk or Npmrcs lh.!con.
<br />rtrd sho contr. h ftr such pn+cr r Nirh xConrEcro(s) li.cnscd pur$'rnr L, rh. Cotrrrrcroi\ l.icctr* ti,*l
<br />I n .rc rtr rnd.r Sccrn,
<br />]IaBf,EBstlOltE rs/llll)!
<br />DE!;LA!AIII}!
<br />I hcrchy rffi ! tlcr p. rlryofpcrjurtoncofrhctblloqin8dc.lirilioos:
<br />-l
<br />hrvc dd trillrmirnrina Ccnili.nr. ofC.iscrrt' S.llln\ur li,$orko! cotr,pctrdnnr, r\ tmvnl.d k hySc.rtr)n:1701)ntlhc
<br />I-rh.r C-.d., f{n rlr F-rlnnna cc ofrhc w.rk ntr *hi.h rhc pcrnril i\ isNcd
<br />_l hrvc rnd willnr.int.inyorkcf compcnsrli.n iNuramc, ds r.qun.dhrsc.tionl7u)oirhctjhorCodc.lorlhcpcrfom!.ccof
<br />rhc work lbr which thn pcnnir is i$ucd M y wortsl .urEnsario. in nrcc cMicr and Fli.y Nhhcr arc
<br />(,?R 2,-
<br />-l
<br />.c ily rhrr in tu pcrfoinBkc .f rh. sork ntr shth rhi\ P.nnir is tski. I \hrll n.r cmph,I any l(r\,n i'r riy n n.r
<br />v, ^ t, hcdrnf, subF-r x' rhc $orkcr' .. rF-trsulior l.ws or Crliraarh. lnd rsrcc rhlr il'l dnnnd hccim suhjccr r,r rh.
<br />workcrs c.nrpcn$rn)n pmlisi,rnsolSccri{nr l?(x).frhc 1,fi, Codc.l shrll. lj]nhwirh cotrDly Nirh rhosc pmlisnnr
<br />WARNINCT Fanurc kJ $curc trorkcrs .. llcns i.i colcralc is u laqtul. rid {hrll sxbj&! .ri c Dlotdr t' aimiD.lFnrlric\ trd
<br />civil 6ncs uF lo onc hundr.d thous.nd do
<br />Sccrbn :1076 of rhc tibor Codc, inrcrcn and,"*,!::L-18 A
<br />.omp.nsdlion. drnEB.s.s providcd lnr thc
<br />I h.,chyxlli,n,tr nlcr Jtn]rr) olt).rJtr') r r lrDr
<br />Ir[gdxAullN
<br />undcryrorisn,n of Chsprq 9 (s,'rmminE wirh s(ib. 7000) or Divisi(,n .1
<br />ot ih. Busincsrrnl t'rol!$n'n\ Gnlc. m<lry
<br />&r /t ,€z-)
<br />?-u-1,.
<br />I hcrcb, alfirm und{ lcnalry of pcrjury lial rhm h . con(ruclion lcndin8 lsctrcy fo, rhe rcrfolmrce of rhc work for whi.n rhii lrmir is
<br />issu.d (Sec. .1097. Civ. C ).
<br />1IISJIAILDICI2IBAIAN
<br />I hcr:by .Jrm1 undcr ,'cnalr y olFrru.y oR ofrhc rolbwing delnr n'ns
<br />D.nmlirion Pcirnirs Ash.{os Nonfi. ion Fcd.rrlR.gulsin,ni (1illc40, Prn6)
<br />-Rcquncd
<br />btt.r of Nolilicarion
<br />I c.nil) rhrr rhc fcddrr relxltrri,nn rcBrdirg r\hno\ r.fnrv,'lrc nor irItl.rhL. k, rhis lxrj.c{
<br />I rcniryrlrr lhnk R.xd rhNrfp liuri(tri M nrcrhri rhcxhnc itrn,nnrior nrotr(r I rgrd b c.,,ny trnh all Cnyand Connr!
<br />ur(ttr r.c\rtrd Srrrc IrN\ rclrrng ro hu (on{tocri(r xlhrrrhyru(lxtri/c r|nc{nr]rivr\ ofrhis Cirydid Cortrry r..it.. u}[ thc
<br />rl . trrtrr(rrJ !'o|.nrfttr
<br /> Dpli.nnl or AA.nl SiBtrhltr *,",q4=/g
<br />el t*,,.s
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />Subf Ioor/VenUlnsulation
<br />Rool Sheathing
<br />Shear Wall
<br />Frami ng
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />ltllason (y
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />A\
<br />FINAL t0-9-tr y.tLltd
<br />Certificate ol Occu pancy
<br />Notes , Remarks, Etc
<br />BUILDING. INSPECTOR RECORD
<br />SLAB Floor
<br />Brown Coat
<br />l.ndcfs Addcs\
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