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Indiana Department of Labor <br />T ` <br />an-dHea-1tl-1Adhn- Stjra--i-�-- "A <br />nd 10 safety <br />-Vat 11 --al M <br />402 West Washington St - ROOM W195 <br />Indianapolis, IN 46204 <br />Phone: (317)232-1979 FAX: (317)233-3790 <br />0 k Qb <br />INVOICE/DEBT COLLECTION NOTICE AJ' -1 <br />Company Name: C & S Masonry Restoration LLC <br />Inspection site: 305 W North Shore Dr., South Bend, IN 46617 <br />Issuance Date: 4/19/2018 <br />Summary of Penalties for Inspection Number: 318096039 <br />Safety Order 1, Serious <br />TOTAL PENALTIES <br />= $6,000.00 <br />= $6,000.00 <br />Pienanitiie-s nre <br />fifteen (15)worki:nc,days ---e.-- <br />' ` "Indiana "f r of tbis notification 11,n] s -o co- nfes ed, Make <br />Your check or money order payable to: "Indana. DOL/IOSHA,,. Please indicate IOSIIA's Inspection <br />Number (indicated above) on the remittance. <br />IOSHA does not agree to any restrictions or conditions or endorsements put on any check or money <br />order for less than full amount due, and will cash the check or money order as if these restrictions <br />conditions, or endorsements do not exist. <br />Corrective action-, taken by you for each afleged violation should be submitted to this office on or about <br />the abatement dates indicated on the Safety Order and Notification of Penalty. <br />A wor I sheet h een provided to assist in providing the required abatement information. A completed <br />co e inf n <br />PY Itr w k heet should be posted at the worksite with the safety order(s). <br />Jerry Land- Date <br />Oil of C <br />Di +Z) struction Safety <br />Safety Order and Notification of Penalty Page 1 (Rev 9/13) <br />