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SITE-WOHK DATE COMMENTS OWNER AUILDER T'EI,CARATION
<br />I hcrchy rfirr undcr lrnilry of rcrjury rhal I aD cx.mnr rio$ rh. conrn.ror' Li.cnsc L.r lor rhc followins lcav'n (Scc 70ll 5
<br />Bu\inc\s ind Protcssion Cmlc): Any Cily or Counry whth rcqrtcs . lI.rit lo consrrucl. rncr. imp,ovc. d.tu'lth 'tr rrBn Jny
<br />stucrorc. priffx, il\ hsuonce. ds. rcqunc\ rhc atpli.mr lo. such pcrmirlo nt a si8ncd srlremnr rhd lr.r sh. i{ li.cns.d pureuanr
<br />lo llrc prcvisions.frh. Conlrrrois Liccnscd l-ru (Chiprcr 9, Co,nmcncnrS wit[ Sccrion ?00o oi Divhn'n 3 or rhc Bxsi".is,nd
<br />Pnn.*n,is Codc)orrMr hcorshc t ercmpr rh.rcfronr and rhcb!\i\ for rhc sllc8cd .i.npri.n Anyvn,hri.n.fSelhnT0ll5hyony
<br />ll)tlicrntforr|).nnnsuhj(rrh..pFlr.ntroacivilpcn,lryornormnrhrtrrivchutrdrcddollam($5(x)).
<br />I.NosncrolrhcnR,tirny.orfty.nrfloycc\wirhwaSes!slhcirslcdrmpcn\dn,i,will o rhc solk ntrd rh (Mrurc i\ nor
<br />i. .n orollcrcd hr $lc (SN 704i1. Busifts{rnJ Ptufcs(n)n\ (1xtc Thc Cotrr..kn r Li.cnsc Liwd.csmr lmlybanotrn.rof
<br />rhcFrr.dt sho I'xild\ or inlln)v$ rh.dnr, atul who d(r\ \uch q.rl hnn\clfor hcrclfor rhmu8h hir or h.t oun crployccs.
<br />piovidcd rhal such improrcmnh m mr i cnlsl or ollrEd for slb li hosr(r lh. huilding or impmvcnrnr h s,kl wirhin on. ,ur
<br />of.onll1Llion. rh.Owncr Buik]cr willhrv.rlr burdcnofptuving rhar hcorshc did nor buikl or nryn,h rhc ttulxny i tlrcpurlr){ol
<br />I..sosncrofrlrpn,ncny,n rcxclu\ivcly.o kr.ri'r! $nh liccn\Lll corrrnn ).of{rucrrhc pn'lc.r (S$ 7{}4,1. Bu\itrc.\
<br />flntl lh)[:\i ('i c:'lhc(rn,rr(nr's l-icctr\.l.nw.locs norrpplyro rno$ncr olpn,p.nywho htri]ds or nnptuvcs rh.rcor.
<br />rnd who.ontrBfor{rchtmjccrssirhxCotrkr.ktr(s)li.cn\crlNi\u.[trrhc(hnrr.doisLiccnscbw)
<br />I rn.r.n,d undcr S&rion A. & P( nrthi! rcr!.n
<br />u!8tr!&arl]utltNtararIrlcl, aarl()!
<br />I hcrrh, flntrr!ndcrncnxlryuf Frjuryomofrhcfi,ll,,*i'rg,[.lrrrri{!,s:
<br />-lhlvcndrillmiint0inrCcnificrlcolConscnlroSclfitrsurclorNorkcdcompcnurt,n.asF)videdtorbysd.rion:17fi)orthcLontr Codc. for thc pcdo unccoflnc *od r.rEhich rh.pnnir $ nsucd.
<br />rnni'\ r{ul My qorkcrr (,nrt.n\di(r NUrr ..fld'cr rkl fx)li.y trtr'nhcr rrc
<br />A./CO,
<br />-- G-)r o o
<br />I..nifyihd nr rhcp.rf.r.urNcofrh. sork ld uhi.hrhir n rnn ( istrcd.l shru nor cnployrnyp!^otr in anynunncr a
<br />{i!srobcqnncsuhjcctrorhcwo*cFconrp.ns.ri,,nluwsofcrlihrnia.rndlsrccrhuriflsh)uldh.coitsubi.rrrrhc a
<br />hrkd^' compcn\arion pi,,vi\i{,ns ofSccrn,i l?(n ofrhc ltr D. (ixlc.l iiall. lonh(iih.onlply wnh rh.$ pmvhiotrr.
<br />WARNINC Frilurc h $.urc *ork rs con{.nsirio. covcnCc ir unl.alirl. rnJ sh.ll nrhjd an cmplorr ro oiminal Irhlric\ nnd!
<br />cilil lincs up io o.c hundEd rhoDetrd
<br />s(linn .m7n.rrhc I Jl..r Cndc, inrcr.n
<br />"'" z/27/'a
<br />-2"trrgD\ n\ Fridrd ln, rh.a
<br />Ihcr.brrfln'ntricrp.rlry.lprrjurythdIrnrlnrNdund$fl,)visninofCh4r$9(.onnlrncnr$withSslion?(n0)oll)ivi\i($:l
<br />of rlr Busincsxnd Prcr'csionsCodc- nl nyliccn\r i\ in tulli(nr rnlrfl..r
<br />a<q azr 3,60
<br />Y;/18 /'
<br />I h(cny rf,'in ! .r,f,trrllyolpcrluryrhd rhcrc is i
<br />irn'cd (Scc :1(P7. Cir C )
<br />hn knditrg o8cncy for lhc psr$nnnc. olrh. sork f(tr ahi.h rhn Pcrmit is
<br />APPI ICANT DECI ARA'II(IN
<br />I horbyi0l utrd.r p.trrlryolt rjury.nc oithc nnnrwingdehnriotr(:
<br />D.nmlirdn P.rnn\ Asb.sos Norifi.dltun rcd$.I Rcgul ions (Tirl.40. Prd6)
<br />Rcquircd knc.olNorilic.lion
<br />_l ccnifyrln'rrhc tcdcralrcExurnrnsrcgrdin8 t (os rcmovll rrc nor rpllic.bt t,
<br />I r8le ro comdy wirh allCnyudd Counry
<br />dircs ofrhh Cilyand Counryro cnrcr upoo rlr
<br />I rcnifyrh l hrvc ftrd rhnnpfli.rltrfl nnd rhn rlrcrhnr i'rln'ful1i nrur(rr
<br />ord ri.cc trl Srnc I rs\ rcld n! h hu'll *'*ff:*^
<br />ah'rc mnti{nrcd nDpcny io! itrspccrion
<br />,\pDln trl or,\xml Si[nrrurr
<br />-t ca^KiL,,,,," l*r/ t e
<br />Set Backs
<br />Forms/Sleel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />SLAB Floor
<br />Subf loor/VenVl nsulalion I
<br />Roof Sheathinq sltulQlr q-.*t -l ly
<br />Shear Wall ll U
<br />Fram in s
<br />lnsulation/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />[/asonry
<br />Pool Fence
<br />T-Bar
<br />Handicap Req
<br />Depuly Final Report
<br />Enqineer Final Report
<br />Flood Zone Certif .
<br />I
<br />FINAL gl2ellt Tq M l ?r)
<br />Certilicate of Occu pancy I I a1
<br />Notes Remarks, Etc
<br />BUILDING- INSPECTOR RECORD
<br />ID/SIG.
<br />5t8I(l
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