|
SITE-WORK DATE ID/SIG.COMMENTS
<br />Set Backs \d ./&/
<br />Forms/Steel/Holdowns \w/a'//
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathinq 813-t8 4c-44 lwtP "b)4Shear Wall to-l\-tg (fuan
<br />Framing ,4-
<br />lnsulalion/Energy lu 1c I a '"7(-Z ./
<br />Drywall tr/t"/,r.Fhaz>c-/6)--
<br />Ext./lnt. Lath /ilttrlv A7lc7rl'
<br />Brown Coal 15'J:c,:'/e ,-z?c.^.t2..4,
<br />lVlasonry
<br />Pool Fence
<br />Handicap Req
<br />Deputy Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />FINAL /z'3-/8 c7 22 O'r-Q^a/
<br />Certiticate of Occu n '2 ?,*
<br />-2/
<br />Notes Remarks EtC
<br />9r
<br />Ar*J"-l-. ",-' (.^h;"4 f -rb
<br />t
<br />oWNFJR BUII,DLR DELCAITATIoN
<br />I hNhy rifinn un{ldr Fnrhy oi Nriury rhd I m cxcmnr iom rhc Conrr.t,F Liccn$ tiw tor rhe iollt,wi'r! rcrsn (Scc 7(r.11 5
<br />Bx\incsl Dtrd ft.i.$hn Codc) ny Cir, nr Coxnl, *hicn rcqDir.s r JEnnil l(, onsrru.t. allcr. ia!,rov.. dcmlhh or rcFn u
<br />slructuic. Fidni irs issuancc.rlsorc+n.\thcrmli.drr{nsuchJinnirn)filc!sisncdnrc'kdrharhcorshcisliccnscdpu^urnr
<br />r, rhc Druv(nrn( .rrrE co,rrndois Liccn\ed UN (Chrfl.' 9, Conn,rrFi0S wirh Scdi'n 7u)O ol Dilnion I ofthc Busincss atrd
<br />l'rclcsior\ Codc)orrhar hc.rshc iscrcnll, rhcrcfronmd lhc h0\n io. rhc !llcgcd rrr'nrrtrn AnyriolationolSccrionT(l:ll5hyiny
<br />aptlicrN r , prrnrir suhjds lic applicrtrrt' rcivilpctrnlryornor nxmlh{n liv. hundrcd dollatr (S50o)
<br />-1.
<br />ff o$ncr or rhc ptup.nt, (n my ctrlnloyccs sirh $4c\ ns lhct {,lc .oi]Pc $rt ion. will do lhe $orh arxl rtr shrm t ml
<br />iNcnd.n orofcrcdl'qslc(SaTlg.l.Buiin.sradFhna\sn,nsCalclhcConraci{r'\lkcnsctr}docsnolaiPlyroanowncrof
<br />rhcF)pcny sho hoikk u inll'tuvls lhcmn. n, q'ho d,B \Eh *o himsclforh.rscllotrhnuAhhirorhcrowncmployes.
<br />nrovidcdlhar such inpmrcnurs m norinrctoldl or offcBl nn qb.lf. h.sscr. rh. huilding or inqmrcmnr h sld *irhin onc )td
<br />orconpLri,n. rtr owNr Buil&r will h{!c rlrc hnrd.D or Ptr,vins rhd rr or ntc did nor huild or nrFrort th. ptuP.ny for lhc PnrF)t or
<br />I l. rso$ncrol rhc pmp.nr. anrcrrlu\i!cly.o.tr3crirrE !irh lrctrs.d co rr.ror\ n) connd.r I
<br />Pn,ls\.n Cldc: l-hc Conhcroi x Liccnsc l-!*docs nor npplyto in.wnd olfrc
<br />nho conrra.lslor ch prcjmr { anh r G,.tr.tun s, liccn{i
<br />-l
<br />ur cxcnD! undcr sccr
<br />DEII.A8AUO!
<br />I hcrcby afi_rnn undcr !cnal', or r.rjxry oIE oflhc rbllowing dcchmlions:
<br />-lhlvcaldsiU@i
<br />nin0Ccnificatcofconscnrk,Sclf.ln\urcnr$o di of,P,n$riotr. .s lrevid.d ror by scc'ion 1700 ol rhc
<br />L{br Codc. for rhc ,ErfornBt. or (hc work ior whi.h rhc pcrmil h issucd
<br />I hr!. rid willnr.inliin *ortcrr co'npcnsarn,n in\rrancr. as rquncdhySection:17(X,ofrhcLrbot(tdc-forrhcE,om'rnr..r
<br />lhc work ror whichrhn pc,mir is i*!.d Mywork.s cd.rFn\ariotr insurlmccmicr ril F,li.ynumbcrrc:
<br />-l
<br />ccniirrhrr in rh. p..foirrrrn.c .frhc work lir which lhis pcnnir i\ i\\ucd.l drllnor cmployrnyPcnon inan! nrnRr
<br />nr nqh LnnrE rrhjcd n) rhc workcr o Ddnsdn)i hss ofCalilanrin. rnd ngm rhrr ifl thould b..om suh'cd n, rht
<br />workcri.onDc!{rri.nlrrcvti{'nsolSc.rii)n:17(X)ofrhclnhtrC.dc.lstull.fonh$irh.onflywirhrhoscrmvisions
<br />IVARNIN(; Fdlur. ri sccurc sorlcr conrpcn\ n'n rovcrrtc is unliwful..trd shnll s,hjccr "n cdll.rcr ro Laimirrl l,cMlrk\ rnd
<br />.ivil fincs uI lo on. hunded rhousand dolh6 1$ lll).Ux))
<br />SNrion 1076.frhc Lntxtr c1xL, ir crcsl lnd arromcy\ iccs
<br />.osl ol.ompcnsrrion. drrnaBcs os Pmvidcd for rhc
<br />DICIABAIIAN
<br />I hcicby nrlirm uni.r l)cnoll, ol lcrjury rhd I rn lidtr{d uM.r lrorision orChllprcr 9(co.n1rn.in8 sirh Sarion 7lxr0).rDivnidr r
<br />of rhc Bu\i'icsand Pmltsi lsConc. uDd nryliccnre n in lull rrcc dkl.ltNr
<br />r- s- (g
<br />q)NiIA]JSIIANIINDINIj.A{iENCI
<br />Ihc'd,ysliflnundrr|.inlryofFrlu.ylh rhcrc Gacondrucri(,n lci.tin8 recNy Lt th. rcrlbnmncc .f rh. *ork for whichrhis Frnir is
<br />issucd (Scc .1097. Civ C )
<br />ttr1klr''s \xnr
<br />-
<br />LJndcl\ Addr$
<br />d.EzuI]dNLIIE!I,ABAIIO!
<br />I hcreby lmm undcr pcnahy or p.rjury onc oirhc tollowins dcclaralion::
<br />O.mliriotr Pcnnih Astrcsro\Norinc.riotr F.dcml Rc8nlorions(lillc40. Pan6)
<br />-Rcqutcd
<br />L.llcr oa Norili.tri.n
<br />I.cnrryrhd rhc rcdcml ,.pllarionr rrrdin! a\h.{ostcnuilarc nor.p/i.a$h h rhis Pmj.cr
<br />_,editythar I hrvcrrdrhn0p,'ltrrionofrlslarclh iof{trm ion ir c.rLrt I agre io mn,rly wirh rll City .nd Counry
<br />.dinrnccs and Srrrc lr$\ rchrnt rcrcsnhrivcs orrhn Ciry md c'outrty nr cnrcr uBnr rh.
<br />ibove Nnriomd prcpcny
<br />.\DDlicnnl or Asenl Sisnaiurc
<br />P.miltu mm. (rrinl)l
<br />J--7-c'
<br />Eiua
<br />BUILDING. INSPECTOR RECORD
<br />,./
<br />Erection Pads
<br />T-Bar
<br />C.ricr:
<br />t g_.8
<br />Licctrsc Cl.ss
<br />t---+---
<br />I
<br />--
|