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SITE.WORK DATE ID/SIG.COMMENTS OWNER BUII,DER DT:T,CARATIoN
<br />I hcrcby afllrnr uMcr pcnahy or trclury Ihnl I Mr cxcnu rmrn rh. Cotrr.cror' l-iccnsc taw lor rhc lollowing rcrw'n (scc 70ll 5
<br />Busi.css and Prclcrsioi Codc), Any Ciiy or Counry which rcquirF a pcrnir k, co.srflcr. alrd, i,npn,!c. dctrFlish ,{ rnJir y
<br />(ruclurc.0iorlo iis issuucc. rlso lcqntcs rlr npplicrnl f{tr suchFnnill,) nlc r signcd srarcnrcnl rhurlEorshc ir li.crstd NNnanr
<br />to thc |novtiotrr orrtr Co.tr.ro.i Liccnscd tjw (Chnpr.r 9. c-onnncn.irg wilh Sccrion 7uD ol Dirision.] oi rhc Busincs and
<br />Pnle$ions Co,lc) or lhor hco!snc n e"Dt rhcrctomind rhc bnsis f.rrhcallcscdcrcdprion Anyli{rarionotsc.rn,nT{J1l5byan!
<br />applic.rfor!pcrnnsuhjcckrh.rpplicrnrbrcivilpcmhyofnotmorcrhrillvchundr.ddolhs($500)
<br />-1.
<br />.s o{nc! oi rhc pmF-ny, or my cmDlo}ecs wirh w08cs !s
<br />'hci
<br />sole conrEns$ ion- $ill do lhc qork and rrt {ture n &r
<br />inrcndcd oro clcd l $lc(Scc70,14.Businc$Mdh.fcs\n,n\Codc,'lhcConkacttr\Li.ci*tiwdNstrot,prlyl.0nowncrof
<br />lhcpoli.ny who huilds or nnlovcs lh.ren.0nd who docs such wrk hinsclio, herrlfor rhrough hir or hcr own cnrhy.cs,
<br />Drovidcd rhnr su.h i.DrownrnN m not i, cndcd or oltcBi tu eh. Il hotrcv$. lhc ttriAiry or nilpnEN n ald wirhin rk )rr
<br />ofconl'kti,n. Ihc Owier Buiud will tuvc rhr h{.dci of pmving rha hc or \hc did tror huild or impmh (hc lotsy for l}f, puqne oi
<br />l. $o*trdol rh.lbtf,,ry, r rcx.lusiv.ly.otrtdcrnr!uirhli.rn\cJ.ont&ttrsh.otrnnr.trtEpr,rcct(Scc ?(l+4. Busnc$
<br />lni PnrbsrhnCo{lc'lhcConlracrr'sl-icc.scL!*doc(n.l0rDlyro!no+nc.olrr)Ilc ysho htriknN imptur$rhcrc.tr,
<br />! qho co.trc( f(, such pR,jc.rs with n Cunnck'n s) licciscd prAU rr, rh.C(r rrcktrk Liccnsc Lrw).
<br />"^,"ay
<br />I hcrcby rllnnr undcr ocnrliyolncrDryonc ofrhc l'ollowirs d.clarutions
<br />-lhalcnrwill'MinrainoCcnincarcotConscnll.Sclflnsutcaar*qkc$ro{.nsnri,,.,r\povidcdrorhysccrion:l?{xroirhcLlbor Codc. lor rhc !.rrbnumc ol thc wod. ior whih rhc Dcrmil h issucd
<br />I hnv. snd uill Bi.rain w.rkcrr'.onpcnsarn insurnnr., a\ rcquircd byScchonlT00ofrhc hhor Cod., for rhc Frfornikc of
<br />rh work for whi.h rhi* l.inir is issld My worl.rL rarr$mrbn insurancc.dnicr at plicy numhcr ec
<br />P.licyNuhbcr Expircs
<br />-l
<br />ccnily rhrr i. rhc ncriormDcc o{rhc $ork aor $hich rhn D.nnir t issu.rl. I \hrll nor cmrby rn, p.fton ir itry n'lnncr
<br />w, ro bcoN shl.crh rhe sorkcr( .o
<br />'npl
<br />n\ar nr h$s.tcrlifomi( rid d8rcc rhd,fI should hccotrE subjcct lo rhc
<br />*orle^.onncnrnli{inpovhn,n\ofSccrnn,.lTfilofrh.tntxtrCodc.l\hrll.f(flheirhcotrflysirhthospmvisioD\.
<br />WAltNlNGr lirilurc to {curc w(rkcrJ..nlpcDsriof covcrhlc i. unlrwlnl ud \hill s'hjccr I] clrpk'ycr t, di'ni'[l Nm]rics ,trd
<br />civil fnrs u!, ro .nc hundrcd lhousond dolles (Sloo.fiI
<br />Scction 1076 ofthc tjbor Codc. ir crcstlndarlorrcy s ltcs
<br />l2Mr!lt!l.l!ll
<br />I hcrcbyrfilnn undcr rcnrhyoffrltrry rhd I im li.cnscd uMcr trovision otChtrDrcr 9lconnrcn.in8 wirh S.cti,n 7O0O).tDitision l
<br />ol thc Bulincs\lnd Pofcisi{nts Cod.. and nryli..h. i\ ir fulltrtr.c iftlc{L.r
<br />Liense Class
<br />-Licctrse
<br />Numher:
<br />Dolc: Con(mctor:
<br />-l
<br />ccnirirlulrhc lqlcrol rcsubrn,n\ rsodin8 a\b.slos rcnn,vd lrc mt lltnlicrblc ro rhis pn)]cd.
<br />l.cdifyrlrrr I hnvc r.rd rhisrp|li.dridrrt ndcrh rh.rbvc inlo ndiin i\co I agre r. conDly$irh all Ciryand coumy
<br />o'dinrncrs trid Srlru Ins\ nhrLn3n) huildift rivesolrhisCiryandCouiryk,ctrr.rutb rlr
<br />xIx'vc nf,nIi,,rn pn,pony ftn i'rlt.ri(rr
<br />,\ppliernt or A[rtrl Silnrtur.:*,"2//2r/1,r'-
<br />Set Backs
<br />Formsi Steel/Holdowns
<br />Erection Pads
<br />UFER Ground
<br />Sublloor/VenVl nsulation
<br />Roof Sheathing
<br />Shear Wall
<br />Framino
<br />lnsulati on/Energy
<br />Drywall
<br />Ext./lnt. Lath
<br />Brown Coat
<br />l\,4aso n ry
<br />Pool Fence
<br />T-Bar
<br />Handicap Beq.
<br />Deputy Final Report
<br />Engineer Final Report
<br />Flood Zone Certif
<br />I -)
<br />o n
<br />Notes, Remafks. Etc I
<br />o
<br />BUILDING- INSPECTOR RECORD
<br />SLAB Floor
<br />FINAL ,//ztt,/ta 1ffi4 z*X),//
<br />Certilicate
<br />.CONSIBIJI.:IIONIEIDIIC.&CINII
<br />I hcrehyrlftnrundcr pcnilr,otpcrj!ryrhd rhrt€ h rconirucrirn lcndinsa!.Ry r rhc P.irontutr.c ol thc wotk rbr which r hi\ t.rhir i\
<br />issucd (S.. 1097, Civ C.l
<br />ATILICANLIECIASIIIaN
<br />I hcrh! tmuftltr pcnilry oip.rjury onc ollhc lollo*in8 dcclaEl,ons:
<br />Dcmniion Pcrmih Asbcnos Norifi.ari.n F.dcral Rc8xlari.n\ (TirLJ0. Pan6)
<br />Rcqrncd hrr.r of N.rifr,ior
<br />tt
<br />I
<br />I
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