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SITE.WORK DATE ID/SIG.COMMENTS OWNER I}I'It,DER DIII,CARATIoN
<br />I h.r.byrfln ui.lor pc rlry {,1l.rjury rhnr I n cr0n|]i ft'ar rh. Coihr.ttrs l-icdi* Lns id rhc f.lkiwnr8 rcn$n (S(71)11.5
<br />Burir.s\ ,rl P(,fdsi(d Gd.): A y Ciry or Cornrt shi.h rcqrnc tf,rtu r. .on{tu.r. aXLy. imnn'vc. dcnNlhh .r rclllt ony
<br />sru.rurc. fri, ro ir\ isunrcc..lso rcquircs rhc llpli.anr in nrh lfnnirro lilcr siSncd slarcnrtrr rhl( hcor shc n liccnsc! puisu.trr
<br />k, rhc ,n,vnins of rh. Conrrcrois Licchcd liw (Chaprcr 9. Conrmcnciig wirh Sccrn,n 7O(n of Division :l ol thc aurircr\ rnd
<br />Pn)fcs$iotrs c.dc) or rhnr tE or shc is cxcmnr rhcrcar)mand rhc l,Ni\ for rhc illcecd cxenlrinr. Afyviolxri.nofSdkrT0:115hyatry
<br />rlrPlicairf{, r ptnnir \ohj6..( rh. lpllicanrbacililpcnrlrvolDoltrmrcrhdllvchundrcddollnrs($5(D)
<br />-1.3\
<br />o*ncr oillE nopcny- or mycmpbyccs *irh wr8.\ $ lhcir $L .omF-nsrri,'n- silldo rhc work dxl th. (tutur L h
<br />inrc cd oronc.edf.rsalciscc7044.Busincs3ndPn)icssion\C.dcThrC.nk&r(tr\l-iccns.Lrqdo.sDota,'Dlyrou.sn.rol
<br />rhcrmpcny wh.hoilds.ri p(,vcs rhcN.. itri *h. des {sh worl h inrr ll or h.^ctf or rhnr8h ht or h.r uwn cry)l.yccs.
<br />pfuvidcd rhd \och infl ovciuh nrc .r i' .lx]d .r offd.il rar {lc lt k,ucv$. rh. hurhi,E or im[orcnrnt h sokl *irhnr onc )tlu
<br />oIc.nq,lcri.tr,lhcOBncr truildq willh.vc thc hurdcn ol p.vi.g rhr h. tr shc di.l ml huild or iqmrc lhc rnFJl, r{tr rh. puqr,* or
<br />I.asosn.rofrhclropdy.rd.x.lu\ivcly.otrkr.rin!$nhli.cnscdconbicrorcro.on(rucrrhcnmicl(Scc?(}1.i.Bosir'cs
<br />lxl hnlcsir Codc lhcC{nlracttr s Liccnsc l,uw(locs nor aDplyl{) anownsorF,rc ywhobxildsorinprovcsthcrc.tr.
<br />ntul sho.ontrhrorsuchlnrjcrswirhrGtrr.r.bdnl.cnscdrunuin[orhcConrracrolsLiccnehw).
<br />I rDcxcDrIr utrdci Scdi,
<br />Drl€ O!.er
<br />rv()RKERS COttlPF-NSATION
<br />DECLAEAIIgX
<br />I hcrchy.rfi n undcr Fnallyolttrjuryonc ollhc lolk'sin8 dcchrulions
<br />-lhavcntrdwillnrinhiiraCcnificdcolConsctrrriSclf.ln{urc(r*orkc.sconrpcnsrion.rsprovidcditrhySc.ri,,n-tTmorrhctibor Codc. tu rhc lnformmc ol rh. wolk for which rh. pcmrir is irsucd
<br />-l
<br />hrvc un $illnrinrair $orkcr'compcn\orion in\urrncc. as rnuted hy sccr ion .l?(n of rh. l ihor C(d.. fd rhc r^_rforrtrrc of
<br />rhc *ork for Bhich rhn Frnir is i\xusl M,worlrcn conu{n{lion insuram. (rricr dd Fnicynuilhc' t cl
<br />7.-,
<br />Iortrv
<br />S1a{< fi.rnJlzt\t56t)oglZ[)ltb
<br />lccnifrrharinihc pcrfon!tuc {)frhc so Inr shirh rhis F-rnirb n\lohccurf, {rtijcd io lhc workc6' .otrrJrns$ iqr hss olCrlibnri
<br />worlcr conl|]cn! ion pmvi\ion\ ol Sffrn,n 3?0o., rhc tntxtr C.dc.
<br />lr IRNING I.r.lx'r h. \, Ln. trr'[c'. .nnFlhxrr.n,,{.':.!r r ui
<br />is is{r .I \hrll orc ll)loyrny$rson ir itry mrllcr
<br />r r l d3Rrid il I lh'rld h.c( r {hj.d t)rlf,
<br />I \hrll.,nnhwirh.otrlp ly sirh rl!,\c frovsidr
<br />rhstul. rtrd \hrll {rhjccl emnlo}cr io ci'niml p.ndric\ and
<br />io ro lhc co( ol conrncnqtriorr. dan(re\ s pn,vidcd for rhcnt) r. otrc lrn lr.,l rhousrkl ,nlrs lSlrXr.(Xrr). r rd(lri-.t"-
<br />A*,
<br />:1076 of rhc ktx/ Cnlc, ir crc{ and inorrcy'( ltcs
<br />b tq LtL
<br />DICIAAAITQN
<br />! hcBh, rlfirm hdcr Fndryofpcrjlry rhar I a'n lien{n undcr rmrisionofChrpier 9 (.o'nftn.,n8 *ilh sdion 70001ofDivhion l
<br />of thc Ausircssand Prcfc$ionr Codc. od nry li.cns n h tulllor.c a clt(l.
<br />lo t1?s{
<br />coNsrBuquoNrl;NDlNiiilil;!.qt
<br />lhcahynmrnrundcrpcnahyorncrjurylhllthcrcnacon(rucrionLndinElgcrcynnrhe|l.rrornukcorlh.*orkturtrhi.Ilhk|tnnih
<br />ksucd(Scc. :llD7,Civ. C )
<br />APTUCtXfD[rLtr^u!]n
<br />, rant y lllinn uidcr l)Cnuli, olFriury orc ofrh. fink,oins dcclorlrnnx
<br />Dc'mlirion Pcrnils Asbc(.s Norificlrion Fcdcnl Rc3ularions rTirlct0. Pina)
<br />-Rcqutcd
<br />! xlcr ol l'lorilEarirn
<br />l.Milirh r rhcfcdcrrltogrhri,,n\ rc8rdi',9 rstr{os r.u)val r.. norrfplicxhlc b rhi\ fojc.r
<br />.-r 0cnili lhd t hrvc rcd Ihn af!licrrionanJ sl clhnrrh.rhorc itrinirnirion i
<br />ordinnn.c\ rnd Sratc rjws Ehrin8 ro buiknr8 connBcriotr. aM h&cbyiurhodc
<br />s coEccr I oE e rommply,irh dllCir,dd Couoly
<br />rcFcsenhriv€s ofrhis cit, lnd cd!.ryro cnid uf.n rtr
<br />',," ^/"//lg
<br />,rf,ny rn 'nsE{hon Nrtxrcs.
<br />t-;:",:::l:Z,,yr A\bi\\O
<br />Set Backs
<br />Forms/Steel/Holdowns tsZ
<br />Erection Pads 4s oe&.l,er-zr
<br />UFER Ground
<br />Subf loor/Vent/lnsu lation
<br />Bggl Sheathing
<br />Shear Wall
<br />Framing
<br />lnsu lation/Energy
<br />Drywall
<br />Brown Coat
<br />Ivlason ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report I
<br />Flood Zone Cenif
<br />FINAL t/zrl,tq#b
<br />Certif icate ol Occupancy
<br />Noles, Remarks , Erc
<br />BUILDING. INSPECTOR RECORD
<br />SLAB Floor
<br />Ext./lnt. Lath
<br />v--/ \.'"
<br />B
<br />btl 116
<br />I
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