|
zoLZ6VC 'euv elues
<br />ezetd Jaluac cl^lc 0z
<br />uorsr^ro
<br />^loles
<br />0ulpllnS
<br />AcuoOV 6urplrng I nt.lluqel.d i
<br />vuoM rsiuuoS
<br />or fclroN
<br />OIVNDR BUII,DER DELCANATDN
<br />lirm utrdcr pcn{hy oi r.rjury rh l Mrcrcmfl lrod Ih Connactor'Liccns. tj* l'or the iollt*inC rcav,n (Scc 70.115
<br />I Prof6sk'n Cod.): Any Cn, or Counry *hi:t ,cquims a Fn l b onslrucr. alrd. im[ovc. demliih ur nlan anv
<br />r ns Nrua'rc. rko rcqutc\ rh. lllplta n \rh Frmir h lilc, signcd {arcnf,nr rhar hcor shc h liccn\cd Illr\uanl
<br />Idr Coirrrckrk Liccnsd tiw (Chapicr 9. ConuEncing wirh Sccrion ?oilo ol Division -1 oi rhc Busi'rcs rnd
<br />thar h€ or shc n crcnpr rh.rcrtufr and rh. hasis fn lhc alhscd ci.n$rion ny violnriotrofsccrion 7l).115 hyan,
<br />,bjEhrhe,mli.nnt roa.ivilpcnallyolnot nurrhanfi!.hutrdrcddollatr(S50o).
<br />-1.r\owmrolrhc|,olrny.ormycmtlorre\wirh*,gd\N\llrn$hconrpc$art.willdolhc*orklndrhc\rutuci{mricndcd orofic.cdforslclSs.7O44,Bosinc\\,ndProrc\sionsCodc:lhcG'tnrackn\L(nscLnwdocsnololPtyh owncrol
<br />rhc rDpen, *h builds or in{,mvcs rhcNn. and *ho &trs such s* hinr\.lror h.isclfor rhmugh hit ot hct o*ncrybyccs.
<br />p, ovidcd thrl su.h inlPnNcnrnrs m nor inrcnddd or onaBl f.r $lc li h.wcw. rlE }[ildi'B or inrPtule' m is $ld withi', ,,n. rr
<br />olconrpbrion. rtr Ovnfi Burkld willhrrc lhc hurdcn ofrtrios rhd h-.. \hc dil ml ttrild or infmvc rhc pnllmr lor rrE PUIIn* or
<br />L asosncrol rhc f)p.ny. dtncr.lu\nllyc.trka.rin8 lirh li.cnscd.. rr ttn s h ..trslru.r rlr Pnrrl{r ( Sc. 7(x-1. 3u\irEs\
<br />!trd hol!s\i,'nCodc:'lhcConh.t'\LiccnscL.wloc\norrpplyhnnowicrofPolrnywhohnild\ornnProvcsrhcrcotr.
<br />rnd who .oDhch ro! such pnj.cc *irh n Conrkrod \ r liccn\cd Nnuanr t) r h. Cin rrcrr'\ Liccnsc h$)
<br />-l
<br />aDe\cnpr undrr s..ro
<br />Drtc Oenei
<br />womuqs' Ll()MPFtlsarrox
<br />DECLTSAIIAN
<br />I h.reby affin und.r r...lryol rcrjuryon. olrhc rblk'winA d*hr.ri,)nr:
<br />I hvc .ri *ill rminrrin n CcnifEarc oa Conqnr nr SclH nsue ln wortcn con dM n,n, ,s lmvidcd {or by Sdrn,n :1700 of rh.
<br />ljh, C.dc. for rh. p9t'orntrncc oflhc*ork lor$hich rh. pennir iq issucd
<br />I hnvc aM will minllin ,.rko' .onpcns nrn nNUaN.. as rcquircd hy scrh. rT([ oi lhc l.ohor ftdc. ror lhc !fl lo nuncc ot
<br />ihc work lnr shichlhhpcrmir i\ i\s!.{ Myworkcs conDcnsnrion insunncc uricr nrd Bnicynumbcro!c:
<br />l'oli.rNu rbcr
<br />-
<br />-lccniitrhlr
<br />inrhc pcrf.ntuftcolrhc work larwhi.h lhn lunnir i\ i(qrd.I (h!llnor cmPby rny Pc^oi inany nx ncr
<br />v, rs t, h..uN subjLrr lo rhc uorkc^ co'!p.n\d n hRsufCrlilonna.lnda8rccrhar ifI \hoold tE ootsubFrrortr
<br />vo*crs ompctrsrltrpn,vist'.sofSccrnnr37(x)olrhc t-rhor Onlc.I s 11. f{,nh$irh.onfly wilI rno{ pnvirnnn
<br />WARNINO. Frilxrc t, {.urc sorkcB cotrrpcnsaiior covcrqc i\ trnhwtul. trd shnllrihjccr an c'rylo)s ki aiminaltcnrlric\ rid
<br />civil linrs trI r. otu hu.d..d rhousrtrd dollan (Sl(x).fixr- in rddnn b Iltr .o{ ol comFn\arn)n. dirmgcs as Provilcd tn rhc
<br />Sccriotr:1076 olrhc lntrtr (irdc, irrcrcn rDd alioaEy r lccs
<br />,,",ft 1!: \!:
<br />I hcrchy,flirnrundcr pcnalryo,pcrjuryrhll I an li.cnrsl und& Prolkion olChlptcr'r (.onrEmitrB wnh Sdion 7000).rr,ivi\i. 1
<br />oI rbc Busin.s\ dd Piorrssior$ Codc. and sy licensc is in aull r.r.c i .frccr
<br />gsls(..3
<br />6- ta- r)r
<br />CI]NEI8IIJX.I!.IENDI CrIGEII}
<br />I hcaby ofllflnufttcr pcnrllyoip.+rr rhrr rh.lt k r sn{flction tndilc agcnry titr rh- P.tfotrrEtrcc ol lhc wor* lor whth thn lEmrir t
<br />hsucd(Scc l0r?. Civ c )
<br />t trdcr ' AJdrc'\
<br />-
<br />A.STLLCANLDtsCLA.BAUQN
<br />I hcrcbylnimrudcr Fnalry.f!.rlury otrc ollhc folk)wins dc.larahotrs:
<br />D.rmlnion Pcrmik-Asbcnos Norifi.,rion F.d.r,l R.gulnrions (l irlc 40. Pad6)
<br />_Rcquncd knd of Norifiorinr
<br />-l.cdifyrh[
<br />rlf Ldcr.l rcgulalions Elrdn,g as$ino\ rcnn,valirc trot rpJrli.rhlc b rhic tio].cr
<br />I ccailylhol I havc rc rhis rt tlicrriondld {rrc rharlhc ahovc iDforrurion i\coftd.I rArccroconul,wirhrllCirymdCounr}
<br />.dimnccs tr.d St.rc lrwsrcUrin! k,buildin8.otr h.rcbyaurhtrir rcprcrntulilcs oflhh Cily and coutrry lo cnlcr unon ltE
<br />nhrc rc rn,ncd fiopc(ylir mtr.lior
<br />",,", ?^', ^ f
<br />,(..) €r,. F-.( ^\c
<br />SITE-WORK DATE
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVlnsulation
<br />Roof Sheathino
<br />Shear Wall
<br />Framing ri \g ,utLl (,
<br />ln s u lation/E ne rqy
<br />Drywall
<br />Ext-/lnt. Lath
<br />Brown Coat
<br />[/aso n ry
<br />Pool Fence
<br />Handicap Req.
<br />Deputy Final Report
<br />Engineer Final Report
<br />/1)FINAL 17t 'tv 4"r7(
<br />Certilicate ol Occupancy
<br />Notes, Remarks, Etc.
<br />T-Bar
<br />Flood Zone Certif .
<br />I
<br />tl
<br />RECORD
|