|
SITE-WORK DATE COMMENTS {)WNER ntJti.DEn Dn!,aaRA rr)N
<br />I hs€hy !fltm undcr pcnolry,,f l,erjury rhlr I im cxcmpl l'mm Ihc (l)nnlctor' Liccnse Llw lor lhc r'olloNins rcav,n rsc.70:ll 5
<br />au!n.\s and Prufcq\i(,n Codc): An, Cny nr Cordy ahich rcqrtcs r Frhir ro .ohsdcr, alrcr. imtbk, d.mlish or E|un 0ny
<br />srruclurc, tritr lo rls issu Ec. also rcquncsrhc rmlicrtrr for su.h r.rmirto filcr siSncd st cmnl lhol hcor snc is lienscJ prrruanl
<br />to thc pmvisi(,N ofthc Cont.dors Lic.trscd hw (Chapr.r 9. C.mnlmirg wilh sc.liotr 70(x) of Division I of rhc Bmirc$ lnd
<br />Pmte$ionr $dc) or lh.r h.orshc h.xcmtlrhclcfronann rl* hasis ror rhcullcEcdcxcm ion AnyviolorionoaSccrionT0.ll5hyflny
<br />rtplicad tua pcrnil suhjalslhe apllicanl lo tr ciyi! pcnilty oI nol morerhrn fin hundrcd dollm (:55lll)
<br />l.is.(trcrorrhcpn,Fd),.orUycN oyL{!rvirh*,gr\r\rh.irv'lccon{crsrn.wrlldolhctro*dtrl11[{nrluEisfr,l
<br />inrrJxhn orolttrc.lr&elc(Sa7{}14.Busin$sxndPr.t$i.nsC.dcthcContrrct,!Iiccnsellwdoc\noirpplyt,x onmr of
<br />rhcpmp.ny *ho hund\ o. tr,Wovs rh.Lnn. r'{ $b des su.h nr* hnn\clfor hcNcllor rhr.ugh hn or hcr o*n cnrpk,}rrs,
<br />rolnhd rh r\u(h inrr^,rc r I rrcnor idcnd.d d oifcrcd r'or \ k II hoNcyci lhc ]riktiu or inlltr.rurnrissold wirhi'ror rr
<br />or.on'plcri(.rhOwmrBuiucrwillharrhchdrncnolpmvinsrhdh:orftdidnorhuildori'l]lx*rrhcpnlI)cntrorlh.Nqi$ol
<br />I. aso+rrolrh.F)ncny. Jmcrclu\imlyconrm.rir8 *irh li.cnqlc. lr!.rostrcon{tucrrhrpnlccr(Sc.7(N-1,3u\i .\\
<br />rxl l'lmlissi(fl Codc l hc Conn rcloa s l-icctrsc l-rw d.cs n.r it'! ly lo rtr .s Nr . f,'n,Dcrr y roiuildsor irprovc\rhcr.o.
<br />nd $ho cotrrEctfor such Im'jccrs wirh L Conhnclons) li.cns'l purunrh rhcCo krckri l.iccn\. lj* l
<br />I .mcrcmpr undd S..rn
<br />IronK[Bs:(ollfl:rtauoNDr!!la^lla!
<br />I hcrchyrlllrDrtr klcr ltrxhyolDcrNryoDCni rhcl"llowljl! dc.hr ri(nI
<br />-l
<br />helc 0.d wilr ntrrnr0 a CcnilEolcofConscnt ro sclr.rNtrrc ror workcF compcn\arion. us p,ovacd tortySsrion.l?00or'hr
<br />L.bor CGic. lol rhc pdloiimicc oI rhc eort for which rhc p.rn h niucd
<br />Fnnir i\ nird Myso.kcn .{nnFr\rrioD in{trr'rccatricr mJ Flicy nun$d arr
<br />Li/t /L //!fs cc)
<br />t / tqL./ /, - oot*Ol- b l- /L/
<br />7
<br />-l
<br />ccnilyih nr rhc Frtunnoncc olllrc work lor qhi.h this Dcflnir i\ i$tr.d.I shrllnolcn{loyatrypcr$r i', nyaunncr
<br />{, tr\r. h.uN hjcdt,'hcworkd\.dnlpcn\rri',nhsaolcxlihrnir.xnd|l3rucihlrirlshourdh..o'msubjcdrolhc
<br />*orkcn compcn\arn,n rn,vi\ion\ ofSccrion lT(xlofrh.lrh' Grlc- l \lBll.lanhwirh $'ntly sirh rhor tmsnions
<br />WARNINC liilurc ro *curc qtrkc( conrl}c.srrion srcn8 is u iwhrl. rnd shrlln'hJ$r o cr.plo)lr ro.Timi, l|rtrktu\nid
<br />ciyil fincs un ro one hundrcd rhousind dolloN ($lfir.ux)). in
<br />Ssrion 3076 oirhc Lotrtr Oide, inlcrcsl lnd irrorrcy r ltcs
<br />-z:::**
<br />1/27+n
<br />I hcrcby rllirm und$ pcnulryofp.rlury rh l rm !i..tr ndcr piovi\ion olChrtrd 9 (connmncnr8 with Ssrhn 7(xX)) ntDivi\ion:l
<br />ol rhc Uu\in.s rnd ltoli$i,)n\ O r- tr,ylirctr\c k in lnlll,nr r clrc.r
<br />j /zt,.Z6Z]1'lf.L ."""*",1
<br />I hcrhy alinnr undcr pcnrllyolpcrJuryrhll rhcrc i\ a c.
<br />is\ucd lScc. :1(D7. Civ C.).
<br />rinn lcndirg l8cncy f.r rhc pcrfornrric. ofrhc work for shich lhh pcnnir is
<br />AIIIIIANLIIES,TAA.II!)N
<br />I hd.hy L,tim und.r pcnrlry orl.rjury Dm olrh. tolh*ing dcclmrians:
<br />Dcholilion Pcnnik.AslEsros Norifi carion FedcEl Rcgul.rions (Tirlc 40. P!n6)
<br />-Rcquncd
<br />t.ncr of NdifEllion
<br />I .cniry rhar fte tcdcral rc8lhrbic reg&ding a$.shs rcnoval arc ..r applic,bl. tu rhk tmi{
<br />I.cdifyrhd I hav. rcrd rhisrttlralFnaMsrrrcrhd rh.rh,rc irf.ntur ..nccr l.Breloco'ntlyuirtlll Cilya Counr!
<br />o trri.r\afd srxrc I r*\ r.h.i8 (, huild r.lr{trr,rivcsofrhisCily,trdCounlylocnlcruFrnrhc
<br />ot-vc mnlnnrcd nrcp.nytu i
<br />Appllc.nl or aent Siamlur€
<br />I4,.Ct?Y'//'s
<br />Set Backs
<br />Forms/Steel/Holdowns
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulation
<br />Roof Sheathing ,rl9l ld 't,yrxlltLt..17q
<br />Shear Wall U\
<br />Framing
<br />lnsulation/Enerqy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />Masonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Deputy Final Report
<br />En gineer Final Report
<br />Flood Zone Certif .
<br />FINAL 9l/{ltf l nryrntet {7)/
<br />Certiticate of Occu pancy rI ,fa v.t-
<br />Notes, Remarks, Etc.
<br />BUILDING- INSPECTOR RECORD
<br />tD/stG.
<br />Erection Pads
<br />(
<br />t n,lcrs Addrc*:
<br />-
|