|
DATE ID/SIG.COMMENTS 0wNtlr BUILDiiR DITLc IL4 ON
<br />I hcrcny llnnn undcr penally of pcrjury rhrr I crcnrnr imrn rhc Conrrrclol Liccn$ ljw nn lhc tollo$in8 rca$n lscc.703l.5
<br />Bu\inc\s r l Prclcssn,n Gdcr ny Ciry or Counry snich rcquirc\ a lcrmi! io mnnrcr. ,lrcr- inln,!c. dc'nni\h ,tr rIUn rny
<br />{ru.rur.. llidb ir\ i\surr.c, rl{, rcquncs rhc 4rplicinr f{n such p.nnir b filo r rigncd (dcnf,nt rhd 1,. or shc is li.ctrscd pursuanr
<br />k' rhc pn,lnnns oI ltE Corrrrcl{tr s l-i.cn\cd L!* (Charrq 9. cl,m encins wirh Scrlion 7u, ot t)ivi\n,n:l orrhd Br\inc\\ lnJ
<br />Pnif.*ions (id.) or rhrr h.or\hc it.kdnrfr ih.nli. md rhc hr\i\ ftn ih. rlhlcd crc Dti,,n Adyriolrri(nofS.crnn?0ll5hyrny
<br />!fpli.rd lbrr Nrnril suhjLr(srhc npnh..nl ki r.ivil!ctrahy.rno! m*crhrtr hvc hundrcd dollnr (35(x)).
<br />I. * ouncr of rh. pn,Fnl. .r ny c lrortrr *irh *r8cs ,s rhcn s,h co rp.n\dn,i. will do rtr w.* .nd dr endm is mt
<br />inl. n oroflbrcd lor {lc (SLr.?01,1. Busim$and ProfcsrioN Coder'lh. C. rucroas l-iens lf,wdocs.or,pplyh3noqkrof
<br />rhcnmlf, y who huildsor inDmvcs rhcren. od eh. docssuchsrl{hinNcllorh.rs.llor$rougn his or hcr own cmploy.ci
<br />F,vidcd rhar such imrnwmnh m frn inrc'ded or ofic(n lo! {lr lt hoscki rh. boildirg or ingEvcmm h eld wi$rn unc f r
<br />oi clnrrLrion. lhc owncr Buikls Nill h3vc r1r hnlcn ol [ovin! thn hc ohhc di] nol build or improvc lnc pmFy ntr ttE purF,* of
<br />_1.{\ *rcr.1rhclnlrny. tmcxc[\ncl]cofircrirF sirh li.ctr\cd.otu{.roA r. con{n'cr rhc Dfulc.r (S.( 7(}.1.1. tlt\ ns.\
<br />rRl Ih,ri\\inCodc'l'h.Conrrarrtr\l,ic.n\cl.rsdoc\nor!!nltn,rtrosmrolln)p.nytrh.hoikl\.ri'n!n{crrh.rcor,
<br />rtrLl $lF.onrr.alarsu.htyoicctswfh Clflru.kr( t lic',{d N' \ux r h rhc C.0kmtn-s t-iccnsc Lrw )
<br />IQBKIBS:TOUIENS TIONDII:I XAUI'N
<br />I hcrcbyrlltnunJcr,'cnrllyol jrcrjuryoNol lhclnlloFirsdcclarrrions
<br />-l
<br />hale otul eillm0inxrin 0 Ccn iicalc oi Consnl ro Scliln$rc for workcr' compen\arion- as p.oidcd iU byS<rionl7(x)orihc
<br />tjho! Cdc, turhc t'dLrmrcc ofuhc {ork for shth rl[ lcrmn is nsucd
<br />_lhltrlndsillmainlrinworkclscompesrrioninsurlocc-isrcqutcdhyseclinn:171I)olrhcljborCodc.nrlhcpcrrnmnccof
<br />rhc sork lnr which lhisFnnil is isslcd My Forker' cornpcn\.t iN insur.ncccaricr n rrli(y nunrbcr uc:
<br />+J-
<br />rhr t^-.larinxnrc ofrh.$ork lnr *h.h rh \ pc' rir n *u.d.l \hrlltror.trlPlor" rn) p.r(r n, rtt rrr drr
<br />s. is r,lrcom \uhjc.t to rhc *ork$L.onDcns rnm hws orcrlilnnri!. Md i8N (h irIshould h.conrc suhjcd blhc
<br />*orkLys.onfcnsarn'nrmvisn,nsolScclionlTtDolrhctrtx*A)dc.lshrll.lonhwrlhconrllyqirhlho*prcvision\
<br />WARNINC: kilurc lo e.urc (orkcn .ompcnsdin, covrr4e is rnlawiul. r d shall rubFlr M .nrrlo)$ r. diminil ,cullics rnd
<br />.ivil finc\ up kr ond hoidr.d rhoo\rtrd dolld6 {$100.000). in uddiri(D k, rhc.on of .onrr.ns.rion. dnNAcs r\ rrovidcd for ihc
<br />s.!rrr r xrra.rrh.Irhr
<br />7,5lrs
<br />4:
<br />g
<br />Dt.t( t 1t,\1't{)N
<br />hy rlft D, trndrr n.nrLly.l porrrl ru liccnrd undcrp()visn,nolChrlr.r9lrioN cn.i'rg wirh sr{im Trvxro
<br />ol rhc lrusirc$ itrd Pd'cssbns Code, xl my liccns is h lirll ture md clrict
<br />b ztt15,EqT{^-Td c'wYC"/
<br />I h.rhIxlfirntrnd.rIr rlryol pcr|uryrhrr rhcm L:ndin! nscncy r(x rhc tcrrortuftc of rhc work fo, Bhth rhh rsmil h
<br />i\{rd rSc. 11r97. Ci\ C )
<br />AIILICJIiLDECLAAAIION
<br />I lEr$y rnim tr ddu Fnrlr, ol r.rlury un. ol rhc f(nk,wi 8 dcclrru! i(ntr
<br />l)cnmlili,)n l'crnril\ Ashc{os Noliiiclrt)n Fidcral RcEuhri,r\ fl irlc,llJ. l'rn6)
<br />Rcquiftd t (cr ofNorifdrhn
<br />-Jl edify thot !hc rcdcralrcsulohons rsarding o+cr..rcm\al!rc mr atFlrohk ro,hn fsiccr
<br />-5ccn if, thd I ltrvc rcad rhN apnhc.li.n aid shrc r hiL rhc abovc inloflmrion is c(mcr. I a8rc lo conlly rnh aU Cny lnd Colnry
<br />ru.ri$. .lkl hcrchy aurlxtrizc rcprcsnhrncs otrhis Cirylnd Counry b cnrcr uBrn rhcodimn.cs iml Shrc L1*\ rcldmB
<br />T y'qo x 5.z9 t*
<br />Set Backs /A
<br />Forms/Steel/Holdowns r Y,W)l)
<br />Erection Pads \.7
<br />UFER Ground
<br />SLAB Floor
<br />Rool Sheathino v,wlal
<br />Shear Wall \A
<br />Framing ';-za4g \ -WIU
<br />lnsulalion/Energy
<br />Drywall (.w tg /14{.b
<br />Ext./lnt. Lath Q ".t t-toY ).\/-80)
<br />Brown Coat
<br />[/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />D eputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certil
<br />^
<br />FINAL Z 7ryra.*//o
<br />ate ol Occupan cy r'/ /:Certif ic
<br />I n
<br />BUILDING- INSPECTOR RECORD
<br />t;
<br />SITE.WORK
<br />Subf loor/Vent/l nsulation
<br />Notes, Remarks, Etc.
<br />I am cx.npi undcr Selion- B. & P C. foi lhk r.nson.
<br />Drt. Os...
<br />Ir r'.^JJ'r.
<br />T?2t
|