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ffiPEcroR REcoRD
<br />SITE-WORK DATE ID/SIG.COMMENTS OWNER BUIt,DER DIILCAT{ATION
<br />I hcrcbt rllt r d.r pcn,lry orFrjury rhai I.flcrcnrtr rion lhc Conkri(tri l-iccn{ uB f.r rhc,nlh{i'r8 r.ason (sid 70ll5
<br />Bu!irc\\ aM l,rolc*ion Cndc): Any Ciry or Cohry $hich rcqoncs , pcnr !) .onrlrucr. !lrs. inrtn,rc, dcnnlish o! tNn i
<br />srrucrurc. l,hrro irs hslmcc. also rcluids rh. lppli. r ld suchrcnni n, filcr \istrcd {,r. rnr lhil hcorshc n liccnscJ ,u^u, r
<br />ro lhc ln,*nnN of d. (.trrrocror's l,trn\cd l:s lchapl.r 9, Co nncNinE wirh Sccri.n 7ffXl of Diri{bn -1 ollhc Bu\i'rcs\ lnJ
<br />Profc$ions Codcror rhar h.or\h. iscr.trrpr rhcrcfr.m.M thc t'rsis lbr lhc alhgcd rxc.rtriotr. Atryvnnnri.notS(rkn70:ll5 hy m,
<br />rpfli.ntrrro.. f.irni subjahrhc appliconr t, acililrcfulryornor ft,cihrtr livc [undrcddollirslS5(D)
<br />-1,
<br />as ownrr or rh. pbp.ny. or nry cnrtlolccs lilh wa8cs ns lhct $k co rt is.rnnr. will do lhc *o* ud rtE ndm i( mr
<br />inrcidcd orofcr.d,irr elc (5(.7044. Boinc$ oid Protcsri.ns Cod.:1hc conrr.clois l-icen\c lns ddr fr, ryP,y lo on osNrof
<br />lhc p$pcdy wn. b,ilGor impr.ks rh.enr ard whodossNh*trl himscllorhercllo!rhnruthhiorhcro'0cnDlorc.s.
<br />roridcd rhrr srh i'npmvcmnls arc mr inrcndc{l or ottcred lor sk lI howekr rlE boildlr8 or iDProvcnEnr h $ld wirhir .trc ,ur
<br />oicotrlplcrion- rh. Owner auilld *ill lm\r Ebrdcnolpovirs llEt hc.r\hedil n.r hoihor im,mE lh. rn'!cn, f ih. puqncof
<br />I. rs.sncrorrh.rtup.ay, dnrcrclusivclyconl .rifs$ilhliccDscJcoh.rffk)c.n{rucrrh.lrojccrlscr'7ur4.Burinc$
<br />ud Pilf.\sior Codc lhcO'nrrscroir l-iccns. Lrw (hcs tror rfflyro rno$ncrofrroptny sho builds or imtnvcs rhcrc.n.
<br />rnd who conk(c f.r uh pmrrIs wilh a Contrldq(, liccned pt^udr ro rhc Ginlrrkr's l-iccn{ U$)
<br />I a .rcnrnr undc, S.crio
<br />]roBtruu:l,.ollrrNlA:IloN
<br />DIiCLABAUq!
<br />I h.rht rifirn uDd.r Fflrlry oiFrjuryoi. ofrhc n)lhwlng dc.l.i.rionsl
<br />I hrvcrid *'ll trri.1.ir rCcniarcalcolConscnr t) Sclll'NUrc tur workcrs' .ofttn$rion. xs PoeiJcd larbyS$riotr l7(x)oIrh.
<br />li}'{trCod..forrhcp.'fonnrN.oirhe*!rknr$hi.hrhcpcnn i\isrtr.d
<br />I hrvcrnd willNirhin !'orkcrs comt.n\rrid1 nruhn.c. r rcquircibyScrri,rlTm.lrhchborCodc.forrhcFcrnn'itr...r
<br />rhc $or I lnr whicn lhn pcrn,ir is i\sNl My wolk.r' co\)cn$lion inwrncc crricr xl F,ltry un$cr c:
<br />Cnd.r
<br />-
<br />-l
<br />ccnifyrh{ irrhc pcrfortunccofrhc work itr shich l[i!n rn i\ isnicd,I shnll nor cmflo] any I,croi innny mntrn !
<br />so .s ro b..om slbjcclrorhc workcn $np. s,rion hwsorcrliroanr. ondnarcc lhtrr il I \tx ld bcto'ft sut cd n'itt
<br />sorkc^' conll{n$r nrn p&vnn,ns of S.rrnrn l?u) of rhc tjhor Codc, I \holl. lonhwirh .ompl, *irh rh.s pmvtior
<br />WAININC: Flilurc r. scurc Norkcn'comrcnsolion covcros. ir unlnshil. rld \hrll subi€cl an c,q'|,'ydr ro dimiml,cmllic\ and
<br />(xl-o(x)). in lddirn,n h rhc .o{ ri conlptns0rion. d! gcs n! Povidcd lor rhe.iv I liN\ up (, o c hu.drcd rhousntul dolloa (
<br />S(ii{,n :ll)76o1 rhdliborC.dc.inlcrc{.tulrno
<br />o"., 9121 118
<br />llLlllErLr-^
<br />I hcrchy ilinN u cr pctrrltyorpcrjlry rhar I an Lccn$C rtrdcr pn,vtion olChspr.r 9 (.o nDminB wnh Sccdon 7000) DfOivhiotr l
<br />of rhr Bu\ilc$ rtrd Pdt\\iuFCo{tc, anJ n,t liccn$ ( i'r ll ll rar.. itrd .l1sr
<br />1a
<br />q l2+l is
<br />I hcrcby rflnnr unncr |Enolly ol r.rjury rhar ir hndirs rrcncy ldr rhc Prlotnmtrcc orrhc sork rd slri.h rhis |Emit ir
<br />n\!cd rsc. 109r. Cn C )
<br />AITLICANLDIELAB{IION
<br />I h.rcby limuodc. p.nrlry olFrjury oN oflhc r'olk,win8 dcthr(rionsl
<br />D.ndition PcirnnsAstEnos Norificlrion Fcd.irl Rcguhrbns (Tnle 40, Pan6)
<br />-Rcquircd
<br />t.xcrof Nori,lcarion
<br />-l
<br />cdi! rhd rh. rcd*rlrc8ubriofls rcs{rding !\bctro\rcnr,lrlar. or nmlic.bL b rhh projccr
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Sublloor/Venti I nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq
<br />lnsulation/Enerqy ll/ t / t,(,\8(
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coal
<br />It/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Ceflif
<br />5q C^thu'\4r,tzJtr/lg r\fi
<br />FINAL B(/1 ),\aY
<br />Certif icate ol Occupancy I
<br />Notes, Remarks, Etc
<br />Dik\C,] -Snpchori
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