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SITE-WORK DATE COMMENTS OWNER AUII,DER DELCAiAAION
<br />I h.rcby rmnn undd tcnrlrt oi pcrjury rh0l I an.rcnll)l rn,nr rhc C.nractoN Liccn* L.q io! thc lollo*ins rcrsn (Sa1,.11.5
<br />Businc$ md hoicsion Codc) Any Ciry or Counry uhich rcquncs o Icrmir ro consr cr- llrcr. impror., dcmolish ,r ftnJn rnl
<br />srruduc. Eitr ro irs h\u!trc.- oho rc{r!tc{ rncapplicanr tu suchrcrnit x,lllcr signcd nd.ftnr rhar h.o. shc is licc.scd Duruotrr
<br />hrhc[ov,siotrsorrtrConko.ktr\l-iftnscdtiw(ch{r.r9.commcn.in8wilhSccrion7(x)0olDivht.]olrhcBu\t'c$lnrt
<br />Pofcsi,nsCodc)orthll hcor!h. hcicnur rhcrcft,natrd rhr b{sis lor rhc allcEcd crcmprion AnyvioldionofSLrlionT0Sl 5hyatry
<br />.pllic.trr f.ra p.nnir subl(ts'hc applicanr ro trcivilrcmhydrnor.rorcrh0n nlc nundrcd dollaF($5OO)
<br />I. N o*ftr or rhc Eorxdy. or ny cnplortrr lirh srC.\ as rhEn $h comFns0rion. will do lhc wok arn thc (rI@ i! n
<br />inrcElcd or orlercd lnr sL (Sa.rO€. Au\incss !n'l h,fc$ions Coac: Th. (-onlacroas l-iefl{ L,w do.. nor rmly h .n ow cr ul
<br />rhcpmlEny who brilds or r{,ro!.s rh.Nlr 0ri'l wh. d(B su.h frrk hnnsclfor hcrellorlhmu8h his or h.r o$n cnploy.cs,
<br />providcd rhar such iqmkmnh d mr inrcndcd or offoan lo, qk lf. lr)scki rlh buildinB ur inlmEm n $B *irhin orc rr
<br />or con{'lcr hn. rhc Owncr Builkl will hor rhc budcn of l]loin8 rhnt hc or she dil mr huild or inDmr rhe pn,Fry ror rr. puqn$ ol
<br />-1.
<br />!sowncrolrhc prupcnr. {,nciclusivclyconrru.rmg wirh licrnsd.onta.lorrocoDrrflcr rhc pn,Fr (Scc 7(!4. AusNs
<br />.nd Pmlisshn cod.r Thc contrrror's Li..nsc Lrw dds u altly i..n ownd oftm!.ny*ho huilds or iDlro{\ rhcreon.
<br />aod who conrecls for such lnjsr{ wirh a Conrrucrorl9 li.cncd pr6ulnr rorhc Conra.bas Li..n\c ljw)
<br />-l
<br />dctcnrpr undcrSsrtr
<br />Dalc Owner
<br />rYoRKr_ii-iiNr PiNs.rrl(N
<br />DD(IAXAIIQN
<br />I hcrcby.llirn undcr pctr{kyolpc.juyo.c ol rh. tulhwiD8 JNlrdiotrs
<br />lhrlcod*illmoinhinaCcniticorcorcl,n*nrroSclflnsurcli,rworkcrs'conrrc.sdbn.asrovid.drorbyScclionlTl]()oirhc
<br />l,txr Cqic, ffflhc pc,fo,runcc olrhe wo,k tu lhth rhc Frmil h issucd.
<br />Al havc ,trd will nrirrtrin workcs comr.ns.rion insuh.... ,s rcquncd by scdion 3?00 or ihe t hor Code. Lr rhc llnonuicc ol
<br />lhc qork for which lhh p.rmir is nsucd. M, work$- .omr.trsalion iNurmcc cMicr aM rolicy numbcr e:
<br />"*",, 5ta1t I-uv^'.1
<br />C 2blt
<br />I ccnifyrh inrhcIrrlu'nrmcofrhcsorktur*hichrhisp.rn,irnissucd.I\hdllnorcployrtryocRrin!trymnrn.r
<br />so N lo bcconE rbjcd to thc workcs on{'.trsri im l.*s ol Crlilnrn Md l3eclhor ilI sh)uli trcom \ubrc.r b rhc
<br />w.r(si cotrrcnsali.tr !,r'vnion\ otScdtD.lT0oollne Lrlry Code.l \holl. tonh*irh compty sirh rh.* fmvni.ns
<br />WARNING: Failurc ro $curc s.rkch .o'hNn\fi. .olcrngc is unldRtul. and shall subjd on cnrploF ro dmiml lf,Mhics anJ
<br />.iril fincs uf ro oft hundrd rhou{trd dolldh ($lm.(XX}). nr aildirion ro thc coq ofconpcnsorion. drm8cs a{ proiidcd lr rhc
<br />Sftrio.]076 ofrhc ljhn Cdl.. n crcitrnd rnonry \ fcc\
<br />"^", 5llo /lv,
<br />I2E!I,A8AIII!N
<br />I hcrchy afirn hder pcnalry or pcrjurt rh'r I n licns.d u.dcr pmvishn orChafl.r I (omrE.cin8 with Scctbn r$O) orDivision l
<br />ol rhc ausirc$ ond Pmfc$bnsCodc. unl nry ltcnr n in fullrbiaandefial
<br />)ol-7 13 (.
<br />511O-lLtt
<br />(alS1XlJlr&N-LlrNIzIIGrIliElLI
<br />h{r.d (Sc. 1097. Cir C )
<br />AIIUCANLDIICLAXAIION
<br />I hcr{)y nmnn u Mcr l](nolty oI n€riu.y om of rhc nntowinR dcchrdlnns
<br />Dcmoliliotr Pc nih- sh.nos Noriiicuriotr I'ldcrol Rcsuldions (Ttlc40. P0n6)
<br />-Rcquircd
<br />L.rrcr of Norificllion
<br />I..niry rhar rhc lcdfnl hlx lrr io ns rcerding ash.sos ft'tuvil ,r. nol ,p/i.ablc to $n pmjccl.
<br />t, ."n,r, ,no, , t'" *,0 ,n,s aptlicorion and slar€ rld Ihc obovc itrionMrion i\ cotr cr I agrr ro .on9ty wnh all ciry trnrl Counry
<br />odinlnccs atrd Siarc Liws rclarins ro blildins consrucriotr. srd hcrcby aurhorizc rcprc{nrariks orrhh Cny ud cou.lylo cnls uJrD thc
<br />aboy. mnrion.d pmFny for insp..rion luT.ss.
<br />,\pplicnnl or A*.nl Signnturc
<br />Zul lllq
<br />bltplu
<br />Set Backs
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Rool Sheathinq
<br />Shear Wall
<br />Framinq ---q7E '/b 3-1,-f,IUL&
<br />lnsu latio n/E nergy
<br />Drywall Sru 4e zoetl lzf?g(
<br />Brown Coal
<br />It4aso n ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />FINAL 5n //r t}'tf,JEn+9,
<br />Certificate of Occu pancy
<br />Notes Remarks, Etc
<br />BUILDING. INSPECTOR RECORD
<br />ID/SIG.
<br />e.r"yl,.u., 921\ 3 56 t7
<br />M &kil)
<br />lctrJ.' . \d,l'cr
<br />Forms/Steel/Holdowns
<br />Ext./lnt. Lath
<br />Flood Zone Certif .
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