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GRADING-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS Owk.aund.r D(l.rii ion
<br />I hcrchy am.,n und.r p€mh, oap€.juryrh.l l3m.x.mpt lonn rh. Conkactotr Lk.nsc L.w lor ltc lolkrsin8 rcrsn (ra ?01, 5 llusincsc
<br />.nd Profssbn cod.) A.y ciry or Counry whrh r.quirn 6 t'.rnn roondtod, rhfi,Inlrorc, d.moliih or rcp.n ey sl rudurc, ,ior ro 9r
<br />tsulmc,llroEqutithcapnlicanrforsuchF.rmirrofiL.sirnn ar.mnt rhar hl or .h. ir liceor.d puNrht b lh. ,mviehhs of rh.
<br />Conlrlcrols Lic.ns.d Lap (Chaprer 9. Comnrmrn-s {nh Seriofl 7000 olDivhnrn I ofrhc Blrin6i..d Profdsions cni.) or rhar h. or
<br />sh. is cx.nn th.i.fron ind fi.6$is aor th. all.Scd .x€Et on .Any violah. of Sclion 7011.5 byanylrplicanl fora p€mir.ohj..rsrh.
<br />nnplicanl to acililp.Mlry olnor fr)E lh!tr fivc hutrdrcd dollon (S500).
<br />L s owmr of rh. Dmrr.ny. or my .Dplo,t6 *nh {u.r $ lh.ir mh conD.nslion. *ill & rh. wort .td rh. .tdduE is mr int.nd.d
<br />o. o0.rcd lor sl. ( Sa 7044, Buiiffi id Pmf.srionr Co{.: Thc Cooltutoa. Liee L6w &B Nl alply lo .n ow*r of thc lrmr.n,
<br />vh. buil.t! o. impovd th.mq .d wh. dB Nct work nielf or h.Mlf or rhmush his or hd om .mploFs, phvid.d thll $ch
<br />imrmvcm.nli arc ml inLffH.ro,Iird forsl..l[ how4r, th. ttuildog or imrmEre i3sld eiltinonc yarol@mpl.riol\ lhe
<br />OwFBlil&r will har th. burd.n ofDovins rhd hc o. slE tur blitd or int6v. for rh. purpo* ofsl.).
<br />l, f,r owrcr oadE pro!.ny, an .xclu.iv.ly conlB€iing w n lic.n*d € retod to @nntud lh. pre.,ftr ( Sc. 7044. Busin6s @d
<br />PDf.sion Cod.: Th. Co Eclor'. Lietr* Lrw do6 mt +ply ro d ow. of p,oFny wlh buildB or inpmB tb.6r, and vho
<br />@ nd. for s.h l,mjdk enh a co tuto(i) lico..d n!runt ro th. co d.ror'e Lh.tr€ las ).
<br />I am .xcnpr under sfrnon .B &PC forrirrcrsn
<br />]YASf,TAS.COMTEIIAIIQN.UECIdSAIIQN
<br />I hftby dflim u.d.r p.nlhy of rcrlury o* ofth. f.lhwin! ddlMrio8:
<br />! hlvc.!d sillmiillin a C.nif!@t. olcoMnt ro S.lf-llttc tr @*6' sop.Ndio,r o pDvi.Ld for by selbn 1700.f lh.
<br />Llbor cod., for rlE dfomam of tlE e* tu ehich rh. Ftun ir is.d.
<br />t havc ad eill mintain e*6 @dr.nsrlion intume. a aquiEd by sftrioo l70o ofrh. L6hor Cod., for ln pcrIontue. of rh.
<br />wort fo. sti.h rhis p.mir ii i3tucd My eorkcft cod!.nsrion inMcc ceio and p.licy nunhd 5rc:
<br />Policy N!mbci_Expir.r:
<br />(l his wrion n..d mr t cotrDl.t.d if th. Frhir is for Orc hundEd dollod t5100) .r l.$)
<br />I c.nify rhar in rh. pcrfortuM of th. ao.t fo. which thi, Fmir i! is.rl. I rh.ll mr .nploy r.y td$n in my minn.r m s lobc.E. bjcl ro rh. mrk.R ' oqEnelion hws olc6lif.mE and a8c rh.t if I rh.uld t .o* rubjel lo lk wo*.6
<br />onD.nslion pmvisioN of Selion 1700 oflt l,bor Codq I lhrll, Ionhwilh smrly wiri rho& po!i.ion!..
<br />D6t.: Appli@nr
<br />wARNlNc: l_silurc to 5dE wortd' omFMrion o\es. ir lnbeill, ,r{ {Bll $$jd .. GnploF b ..jointl p.Mllid ,.d civil
<br />fM op ro.ft bundEd rt usd dolls (l loo,om),in.ddnh blh.con of.ohp.Bllioll. drrEEd a pbviH forllE Scrion ]076 ol
<br />$c Lrtoico&. int.E r 5rd lomy'! fd.
<br />LlcEtsI[tollSacl0Sl-Drcuaar&!
<br />I h.cby lllim $dd rlMly of p.ru,y rhtl I u li6ed u.dd pmvnio. of Cn pt( I (@lE@eins eitb setion ?000) or Divhion I of
<br />lL B!IiIB md Prcf.*ioN Co&, .d my licm n in ftU foE. .,n .f,dt.
<br />qAAEIf,IJCJIANIIBIIICIGIXqI
<br />I h.Eby.mrm un.lcr D.mliy of n€dury rhd $.r. is. sn rrucrio. l.ndins .s.my t r thc psfomnc.of lh. wort for which rhis r.rd r
<br />ku.rl (Ss 11197, Civ C.)
<br />AITUCAT].TDIiCIASAIIITN
<br />Dcho[rion P.rnnsAsb.rosNonncorion lr.deral Rcrn hrn'$ (1nL 40, Pdd 6)
<br />Reqxt d lr(rotNonficari.n
<br />_l c.n ify ihd
<br />'h.
<br />f.n ,.l rcg!,ohN ESsding $n iloi Enrhl rE mt .mlicabl. lo fiis pmlct
<br />I c.dify rhar I h!v. rcld rhii rFl,licarion lrd ilar.lh. !tbv. inform.tion ir @ftcr I alrc lo conply sirh rll cily ud Counly
<br />ordimm* and st . L.ws Elo{in8 nd hd.by aurhorn! rrR.nlrtiv.s of lhis Cny .nd Co!trly lo dl6 lrrn lh.
<br />alElc 'ncnlhn d DmrEny aor
<br />,o,.* *,*lo,r*u,*_
<br />Preliminary Soil Report
<br />Excavation
<br />Fills
<br />Sub Drains
<br />Buttresses
<br />Soils/Geology Report
<br />Statement of Compaction
<br />Compaction Report
<br />Flood Elevation Cert.
<br />Paving
<br />Sub Grade
<br />Aggregate Base
<br />Water Test & Seal Coat
<br />Asphalt Concrete
<br />Soils Eng. Cert.
<br />Rough Grading Release
<br />Final Civil Cert.
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<br />FINAL b-7-tK }r.Wlb
<br />Notes, Remarks, Etc.
<br />Dlt : Co r.cror:
<br />N)1..t6 l)./
<br />*,,,'F/t-/r !o*) rr
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