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Itrr-o{tvc- rNSPEcroR REcoRD
<br />cor,illv|ENTSSITE-WORK DATE ID/SIG.OWNER DUILOER DELCARA ION
<br />I hcrcby 0inirn undcr ,.n y or pcqury rhar I rn crcnpr lDnr rhc onractos LtcnE tiw for lnt followilrs r.asoD rscc '70] 1.5
<br />!u\inc$ and P,ofcssion Codc) A.y Ciry or Coutrly which rcqurcs a N,nrir b cotrirud. dlr.r. improv.. dcnmlhh;r rcNtr r t
<br />iru.rur.. prior lo irs nsuancc- slw rcqutcs rh. {rlic0nl lor such [Ermir lo tica siSned {dcmnr rh{r hcor shc h liccn.cd tu;ruanr
<br />h rhc Eovnions oflh. Contracror's Licen*d tnw (Chrpicr 9- CodmctuinE *irh S..rn,n 7fiXl of Divi\ion.l ol th. Busin.s rnd
<br />Pn,rc*i,,nsC.dc)orihar hcorshc iscrcmpr lhercfroflond rhcbrsn n,rhc rllqcd cxc.urt Any violariotr ofse.^tion ?0ll 5bya.y
<br />rp!liconlror.nimilrubj(tsthcrttlic,nrua.ivilncouhyofnotnrncrhanfivchudrcddollarIS5OO).
<br />I. as owmrorrhc FnrFny. or mycmpk,rccs siih *a8cs !s lhcn sob onrlrnsitio.- willdo ltr sork od rhc slurue i rcr
<br />inlcndcn or oftrcd for sh lse.7(lt4, ausincs Prof.ssn,n\ Cdle Thc G,nh.ror'\ Li.cn{ L2w des nor ,prly b m ownci oI
<br />rhc pmlcny wtx, hil\ or impmvcs rh.rcon- nnd uho docs sEh eorl himscll or hcrclf or thmuSh his or hcr oytr c pbyccs.
<br />[ovidcd rh0r such inrr.n'mnh m mr, c',Ld or oftced lu sL. llihowcrcr. rlr buitlins or nryrevcmnt is bld wilhirorc ]rtr
<br />ur.onpkri'n. rh. O*ncr Buikl., willh!rc rhc l,urdctr oiroving
<br />'tur
<br />l[ or shc dd tror build or imprcv. thc lmtdy r.r ri* t'urr.$ or
<br />.alfii""",.r rn" r",*nr. m.x.h\iv.tyconklcrins wirh ti.cnscd conhci{ns ro €ndfl.r rtf, rmFr (sr.. ?otrt. Bu\i..s\
<br />and tltrri\sh Codc: rhc Conlrrcloi s t-iccn€ hq docs nur rpl,l, t, .n ownf or nrop. y who builds or inrlrovcs thcrcon.
<br />oDd wh. co ncls for srch rr.l.ch *irh d C.mn'.ro(sr liccnscd Iur\urnr rorhe Conradois l-iens. t:w)
<br />-lmcxcm
<br />uDdcr Scctiotr ,B &PC for rhk rci(rr
<br />Dnre'
<br />rvonxrnit:rinrpins,ruor.r
<br />I)ECI"A.BAIION
<br />I hcrcby rfinDUndcr Fmlryolpcrjuryom orlh. rollowiry dc.hrurn ns:
<br />!a h.rr .rd Nill rn.inrrir a CcnirE.t. of Coiscfl b S.lf ln{rc lir $brkd^' .o l*hsirion. tu lt)lidcJ f.r hy Sc.rion lT00 ol r hc
<br />L.hn Codc. for thc lcrformadc. ollhc work fd whth rhc pcnnir h hsucd
<br />_l havcand Billmrinloin wortcm .ompctrsarion insur.ncc,,s rcquncd hyscclion 37(xrol lhc Lrhor C(lc.li'r lhc Frlo.nEncc oi
<br />rhc Nork lnrwnichlhn Nirnil is isu{d M}{ortcri conrrcnurion i$urrtrcc.iriq andFlicy.uftcr rc:
<br />c*r",, -a&]t e 4,.o1
<br />I ccni!rhrr in rhc lcrlbnmn.c,)ilh. work tnr shichrhi!acrnil is is\ucd. Ishrlltror cmployinypcron in rny 'mnNrq, ro h.corE suh]cd k rhc !d kc* .onrF-r\rri( hw\ ol Crlir(riir, rtrd 4rc rh ifI(hould lf,.onr suhlccrhrhc
<br />no.kc.i.onll[trsdhnpn)vi\ion\olSc.riotr37U)oirhctihtrCudc.l\hxll.lidhwrrhcomDlywilhrhostrovisiors
<br />l'lAiNlNC F,ilurct,{crrcktrkcn.omncneri{nrcovcnscislolanhl.itrd\h!lln,hjcdrncnrpl{iycrn)ri irrlFi hi$rnd
<br />c'v1l fii.s utr ti.n.lruntlrcd rhorsr dolhs (Sllx)-(xx))- i. lddirbn ro rhc.osr olconuLn\Jrnnr. Jan Ecsr\r.ov cJntrrho
<br />S(rn I)76 ofrhc lrhr Cod.. i'ncrcn rnd rnon,ry \lcr\
<br />""",A. lS tV
<br />ITIiCLIXAIIO!
<br />I hcrcby ulfirn undcr l}cnallyoipciurylhar I ar lienrt undcr rmvki.n oI Chrflcr I (onrmnci.s wirh Scclion 7O@) orDivi\nrn.l
<br />of lhc Busincssand PmIcsiorN Codc,ond nry liccnr is i. full rar.! aid cfL.r.
<br />a3o1 L
<br />3 t3i3
<br />AIPIIIANLIECI.ABA.II!]N
<br />I trnby dinnuMcr l.Mlrt of tcrjury dtu of rhc folk,wi.g dcclrdionr:
<br />D.mhtion Pcnnns Arb.ios Nor inc{ ion FcdealRcgul ions (Tirlc.l0. Pan6)
<br />Rcquircd ktrcr ol Norifi .dtn)n
<br />ar""niry,r,, ,h" i.a".t ^r,hrnnrs ,csud iis usbc(os rcN'vur!rc Dor lpnlicalrlc ro rhN prcjccr
<br />al.cdiryrh l hrk ,cftl rhis applicrr ion arrl rrrc rhar rlr !hov. inrirturn,n ir .on.!I. l l8tur b.. lpl! wilh dll Cir, ,trd Counry
<br />ordinrr.srndSrar.l-awsrcLningi.huilding..nitucri{4mdhcrch, rhori2rr.PI {nrdivcsofrhirCiryandCoutrlylocnrsutE.fic
<br />rbvc nr ri{,ncd protcdy lor lnspn..rion puross
<br />A|)pli(nnlor A,rcnl Signtrlum
<br />""^r""n ^",OnnU, M, Cr7 b-r.
<br />u",S tt l)
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Rool Sheathing glt*ltg /,ur(9)0, no( q-too( cJlopslug,
<br />Shear Wall tlsotall{.2; /;r/r"
<br />Framino
<br />lnsulation/Energy
<br />Qrywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />lvlasonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req.
<br />Deputy Final Beport
<br />Enqineer Final Report
<br />Flood Zone Certif
<br />FINAL 8l7.ltl ,'(,'(r( ?(/i )
<br />Notes Remarks, Etc
<br />Subf loor/Vent/l nsulation
<br />Certif icate ol Occupancy
<br />t,,txy n *,*, I|Garl-cl r-t"*, 0,e 19
<br />CANSIIIIEIIQNIINI)INC.ACEN1:I
<br />I hcr.h, rllirnrund.! t--nollyofpcoulyrhrr rhcrc n a conslDdion hndin8 lgcncy l'or rhc pernnmn.e olric $.rk lor ahich rhn Frn,ir ir
<br />issucdlScc. :lLn)7,Civ. C )
<br />I cn.lc. , N."N
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