|
SITE-WORK DATE IDiSIG.COMMENTS OWNI'R BUTLDER DELCAR TION
<br />I hdrby a'Ifm uid€r prn,lry ot p.rjrry rha! I am qemfl frcm rhc Co r!cb6 l-i.cn{ l-nw nx rhc r.ubwinB rmo. (s...70] 1 .5
<br />Ausircss ,nd Profcsio. Codc): Any Cxy or Cou.ry whkh rcqut \ r FnDir k, $n{fl.t. ,Xd. nnprovc, dcmlhh nr rclr{n y
<br />slructurc. Drior Io ils isurmc..lso lcquics lhcapFlianl for suchFnDilro filc ! stncd (ltcnEnl lhal lrorshc is li(nEd plFunl
<br />to (h. pmv(iotrs of rhc Cont0croar Li&nscd ttrw (Chrflcr 9. Co'nmking *ith Scdion 7ffL of Divtion I of lhe Bucirc$ lnd
<br />Pmlt$ionsCodcr orlhar tEorshc iscrcnDl thcrclron 0nd rhc b.sis forrhcollcrcdcxcmplion. A,yviolarionoiSccri,n 70.r15 6y"ny
<br />|Ptlicant tu r pemn slhjNrsrhe +plicafl ro!.ivilrcnlhlotnot mre rhd fivc hundrsdd.ll,^ (s500)
<br />l.,sosftiorrhcpmtrnt.ornycntnrlEswirhRa!.\asrlf,nk,h.Drtcns.rn.qillnollEso*.ndrheslnderisfrn
<br />idc{lcd orofcrcd r'or srlc (SN.?()14. Eusirrsand Profcssio.s Code: The Ca rrcroi! l-i.cn\e L!$doexnorapplyiodiown.ror
<br />rhc fsn dy who huild. or in{n,vcs rhmnr. dshodoc.fl.hwo&hnnsclfarhcFclforrhmuahhhorhcrow.cmployccs.
<br />pruvid.drhrr such inlPlo!.tu.h m n inttrdcd or olTcrcd nx sak lL fu)Nc\s. rh. buildi'rt or imtlov.,fttrr is $ld sirhir otrc tqtr
<br />or.o'rylcrion. rhc Osrcr BuiLIcr *ill hrvc rhc burdcnolI'olinS rhul hc or \hd did 'rn S{ikl or irw.vr rhc pmlcdy lor lhc putn$nf
<br />l.r\.{mrolih.tnpcny,m,crrlu\ivclyconrrdingsirhlicctr{d.ofrr.tnat,$n{tu.rrh.l)iojc.r(S..7(x-l.l]!qncs(
<br />kl hsf(sssfl Codr 'lhc On ncrtr-s t-l..trsc Lrwdocc nor iptlyr) rtrotrncr ol,'roDcriywho huilds or iromvcs rh.rcon.
<br />rnd *h. conrBc* lqsuchpr)Jccr\anhrConta.r.n,liccnscd pur\uanrn,rhcCoitrrtrtr'\ Liccisc ljw)
<br />I afr.rcmpr undcr Sdrbn .4.&P.C fdrhkr.as.n
<br />Oat.
<br />lloBtrE8Sl:AUl[NlArloN
<br />DECI,AtrAIIOI
<br />I hrrcb, affiiin und.r lcnrhroflerJutyoi. ofrhc t{,llowi'rE dNlararn,ns
<br />I hrvc rnd $ill nuinrair C.nificrrcnfconsc bSclflnsurc nworlcn'ortri\dn.rspii'vidcdtorbySL\rionl7(x)olrh.
<br />I rtxrC{rlc. i6rh. pcrfonEDccorrhc sorl lo{hichrhc pcnnir i\ i\\ucd
<br />I havrnnd will.ri ri work.rs ..nrFns i.n iNurrncc. !\ icquircd b, SLrrion.1700 olrhc L0bor Code.Ior rhd pcrforntancc ol
<br />rhc trork lor which rhis p.anir is nsucd Myworkcs compctrsarh lNUm cc.iiiicr xlt'.li.y nunrh.. !rc:
<br />. ?a>..-.-rz > e-1*
<br />(lo* C-cttO +o 2_
<br />-Exptcs:
<br />z.z4.r ",
<br />I.cnrfyrhd inrhc ncrtornr colrlrwortfdrwhahrhisp.rnrn$isucd,Ishrllnolcnlloyanypcsoninanymnlcr
<br />s as ro bc@m subjcct to thc w.*cN ompcns ion lausofcnliaorni!. lnd!8rcc rhlr ifl sh,trld hcoft robi*r t, tt{
<br />woltcrs mrycnslrionrmvhions oaScclion.lTmoflhe titsr Codc,I shall.lonhwnhcomply wirh iho€ porGi.ni
<br />WARNING: Faihrc r, $curc workcil co lE.\ari()n .uv.asu i\ r luwful- ond shlll rubr$r an c.ployrr b.n nrl Fnrlris und
<br />civil fioes up kr onc hundrcd rhousn.l dollar (Sl0o.o(xlr. in adnirion h rh. cod oI codpc.q'n,n, datug.s as providcd n)r rtr
<br />Ssrion 1076ofrhe Lltry Gnq ilrclcsr ud arromy s fccs
<br />rrsre:' q'lb irpprronr:*-
<br />I ICFNSUD C(tN]',R.\r'Irl
<br />D!;!taa r()ll
<br />I hcrb, rffirm undc. pctrtrlty oI !.rjury Ihol I !m licctrsd undcr pmvision olChllrcr 9 (conmcrcins virfi Sccloi 70(0) orDivhion:l
<br />of lhc Busiri.ssand Pmfcssi.rNCodc. ard myliccnsc k htuU fom rrd ctfccl.c.Bal.
<br />O@ U(. C<,b (c I
<br />D.r", - q-l O -a O c"^*a*,* 4+-lf e=aG
<br />CAIIIBI,]gIIANIIIDIM.AGINII
<br />I hcrchy rafirn, undcr FialryofFrjrry rhar rhc,c h ! coisrrucrion rinding de.fty tnr rh. p.dnnun.c ofrhc Eork for ehich lhn pcrmi n
<br />h$cd (Scc.3097. Ci!. C ).
<br />AITI.ICANLDE.CIA8ATION
<br />I hcEny dnnn u ftcr ncnrlly ol Dcriury onc ol lhc lnllowin[ dcclnrarions:
<br />Dcnbliln Pc.rnirsAsb.(os Norifi.ation kdcr.l RcBulations (_Iillc.O, l.n6r
<br />Rcquircd L.rlcr of Norifi calion
<br />_l ccniryrha' rnc tcderal rcrrhrtnF Esardi.B ashcstx rcn,valrr. ior.pnli.nbl. r. rhis |x j.cr
<br />tlracdirr rhar I hivc rcad rh,s npplid(ion rnl srlcrhd rhc ibovc i.ro utrotr i\concct l aFEr lo c.mprr sirh rrl c y,trdCiunry
<br />ordinanc.s rnd Si,c b$s mbrin8 ro buiidine.onstu tion. ,nd h.r.byaurhoria.c[csenr0lircs olthh Cilyand Counlt k, cnrd x[x,. rli
<br />rtxrc'mnrn,n.d pmp.n, for insFcri{nr
<br />Annlionl or Asenl Signolur:)(\
<br />Pemitm n.me rpdtrO: >L
<br />4-lgz6,(-?
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framinq
<br />ln sulation/Energy
<br />Drywall
<br />Exl./lnt. Lath
<br />Brown Coal
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif.
<br />/1
<br />FINAL ///R/b(-*-L rt)
<br />Certilicate of Occu '(/pancy
<br />Notes, Remarks, Etc.
<br />-,
<br />BUILDING- INSPECTOR RECORD
<br />L1id.''. AJdrc$
|