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SITE-WORK DATE ID/SIG.COMMENTS OWNER BUN-DER DILCAR TION
<br />I hcrcby alfin, undcr penalryorFrjury rh,r I an crcnfl loin $c Co racroF I-iLU{ btr rar rhc,ollosirr8 tcohn lscc70.11t
<br />B.sin.s rd Pn,tcsnr Codc): Ary Ciiy or Coutrly whi.h rcquncs r Fnnir ro mtr{rud. llrcr. itnProvc, dc r,lish or rPair int
<br />srndur.. pri,r. irs issdrm.. rko rcquidr rhc,rdra nn suchtcnnir to lilcoriencd ndcm rhar hco.shc h liccNcd IruFroi
<br />r. rhc Fovhions of tlE Conrractors l.iccn$d trw lch+rcr 9, conmtrciDs *irh Sccrn)n 7(x)O or Dirriotr :l ol rhc Busincs rnd
<br />Prcicsions Codc)orrhrt hcorshe iscrcrnpt rhcelhn' d rh. h,sis hr lhc!llcccdcrcnlrri r.Atry!iol!lionolSccrionTl).ll5by,ny
<br />lpplicanr for aIf,rnir ub).".-ts rhc nptlic!trr ro acivilpcnaltyofn.rf,or.rhM fivc hnndreddolluF(S5(xr).
<br />{-4l a\ ,,*ncrolrhc nrnrEir. urn'ycn'rLi}cr\ r h tJscs rs lhcir mlc conrp.!\alion. sill Jo rh. wo* ud lhc stndua i! Nr\i'trcrn.d rultcrc'lf,,elclSd7u14.Buqncnondltntcssi.rsCodc:'Ih.Conhn.r.r'!LncscLr*docsnoraptlyhrh.sncrol
<br />rhc pmpcny who hilds or i'nl,oks rh.ftotr, n Blx, dds su.h 8.rl hi'nsclr or hcrsclforrhronShhi\orhcro$ncarPkryccs,
<br />phvidcd rhar suc[ imnmrnrnk r nor i' c ]dl or ofiarci f(, slc. li lnweEr. rh. 6uildi.3 or i'npnr.m is$H,irhi ooc ]mt
<br />ot.o'rll)Lrt.drOwncrauidcrsillhlvcrl'.hnrdenolnovinsth{trorsh.dxlmtholllorinrPro!.|h.PmFnyfitrhc!u{r'$oi
<br />I.r\ sftr ol rhc ,rcI'(ny. aD ciclusivcly cont!.ring r irh lic.tr\.d cotrta.lts ro cu (rud ltf, pr+cr isc 71|lil. Bu\ir'c{
<br />tuxl B!l!$hnCodc'lhcC.ntu.nx\l-ic.nscLawdo*iorrtplyk,ino\rcroln(,Pcny$hnluildsorrmprortsrhcrcon.
<br />rn.l *ho conrru( r(tr su.h pioj.crs s h{Connacl,tr(s)ln_.trrdnu^!r t)rh.Cunkrcnnsl-lcens.lrsr
<br />I jnuxcmpr utrdcr S..tbn_.
<br />,,,",, '7-,c- /tr u.*. X_
<br />I hcrchy rllj'rundcr pcnalryolFcrjurronc olrhc tulk)trin8 d..hdirnr!
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<br />l-at'ff Cql.- for rhc Frfornun.c o r rhc work fd nhi.h rhc lxnnir ir i\sucJ
<br />I hn\t rtrd willnrnnrr trolkcn (omp.nsrlbn nNtrrrn.c. x\ rcqotcd hySccrion:1701)oillrc I xhorCodt. rdr[c NnnmuNcol
<br />rhc q ork for { hith r his !.rnrit is hsrcd My tr orkcN conFnsrrbn in\!rrr. Qffi.r md Policy ru mbcr r.
<br />(;l((nrryrh mrhcncrl,mun(.rlr'cu,trrror*r'trhrlrilt).nnilisi\\ucd.I\hallnorcnfl(,yn!lrr\ inrnymrnmr
<br />-,''( h' h". .nr {1.1,r"., r(.4a!..rrtu}irr..l.'u,. Crli'o'q .Jr.l 'U'n''li' l\noul,ltt."r (\'hi, r,rl'.
<br />qorkcr( conlpcn\rri,,i pniri\ion( ulScdim:17(lOollhc trti, Codc.l \hall. f.nhs h. nDly!irhrho{'IrrisnN
<br />WARNINC: Frilurc b $curc *orkcr' conpcNari,,i ..r. !c ir uDlt(ul. !!d sl ll \ubt.r r cnrlltrycr ro rininal pcmhi\ itrd
<br />\((rir 1076.r'!h.I xhtr (ixl.. i'norcn J n f"rr-'\1c.\
<br />u,r". , 7-21 -17 ><
<br />I2L(lI-BJlt!.)}
<br />I hrrcby ln rundcr J).nrlryolpcrjury rh!rI anr licn{d undrr Itro!iri' ofChrPrqI(co'nnf,ncn,3wirhSc.rion71100)oll)ivi\nn,:l
<br />ol rhc Btr\i'rs r.d PloLsk,nsCodc. ard nrvli.cn* is in tiillinrcc clTc.r
<br />CANEISITEru)NTEIDINg.AJJ.ENII
<br />I hcEhy rlnnnundcr penrlrrurl{rjurylh,r rluc n,.onirucri,)n h in!r!.ItrJ_l.rrhcNrlormrccolrhc$orknnrhichrhN0cirnirh
<br />is$cd1S.. 1097.Cn C )
<br />lrdd$ s Nrtrr:-
<br />A.TIUCANLD&CI.AAAIIJN
<br />I trrcby allinn unncr pcnlhy orBrlury.N olrhc lbllowin8 d.clar!'ions
<br />Dcmlirio. Pcrmirs A\hcdos Norificrrnrn F.ili,t Rctuhrn)ns lTillc.r), r'rn6)
<br />-Rcquncd
<br />kllc! ot N.rifi cdidn
<br />I ccnifyrhdr rh. fcdcrnl rcSu lr l i( )ns rcBa(ling r\bcno\ r.nn,rrl rrc nor rtpliciblc lo lhGF,jc.r
<br />kI'cnrlyr[{ I hrve rcrd rhi\!pplicrii,)n rrlnrrcrhni rlr rtrrc irnnrn{lnr n.onc.r lrgrek}.otrI]li"(ilhnllCirr"rndcounrt
<br />ncc\rtrd Stdc Lrssmhrin8lo htriLlingcotrdtucri(nr. klhcrchy.urMrtcr.[c\.nrrr'vrsufrhl\CityrNlC.utrryt)rnr.ruF,nr}f
<br />lll,vc rh-nr oNd nnltny tur insl]c(ri(,r NrNsc\
<br />h,".7-24-/3'l|)Dli(anl or A(rnl Si! {1"fr
<br />t'rnnir( nnN lDnnl): X htafuT< -L-z<a<z-
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />SLAB Floor
<br />Roof Sheathinq
<br />Shear Wall
<br />Framing
<br />ln s u lation/E nerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Ir/lasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />Enoineer Final Report
<br />Flood Zone Certif .
<br />a -)
<br />FINAL X/l//rY #4u
<br />Certilicate ol Occu n
<br />Notes, Remarks, Etc.
<br />--)
<br />BUILDING. INSPECTOR RECORD
<br />trndcr s AJdrc$:
<br />Set Backs
<br />UFER Ground
<br />Subf loor/Vent/l nsulation
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