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PLUMBING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG,COMMENTS O\!NI'T AUILDIJR DI)LCARA'I]ON <br />I hcr.hy inirm under rEMIy ol n.!jur) rhar t a erenrrr lmm rhe contridou l-rcctrse Lrw,nrrh. iollo*ins rca$n (s.c?0J15 <br />Rusiness Md hof.seon cod.) Any ciry or counry *h:ch r.qoncr . nm nr q,nnru.r, !lrq, i.rnrolc, dcnonsh or n .r rny <br />{tucrurq priq b r 6ru.n..rl$rcqun.slhc.pllicadlorsuchp.anitrolilernsrcdarrctrf,'rhdhco!shcN[ccnsedpursanl <br />ro rh. pmvsions oftlE (-.nlro.ror r t-i.en*d l.sc (Ch0rrrer t). ('onntncrn! {irh Scctmn ?(m0 ofDivFion.l 6rrh. Bu$nlss tnd <br />Pn) Iosnnx co&) or rhar lrorsh. hcrchpr rh.rcfiom .nd tfu h.si rhr rhcillcscdcrcnDrt,n Anyrioli'$nofs.chn 70115 hyiny <br />ar,'lrci lirr tr ,rmnr suircch rhe onphcanr ro a crvil Demlry of mr rmE rhan lit hundftrl dollam (!t00) <br />-L <br />ai ohn of th. tmDcny. o! my.nptoFr wih wa86 s thcn $t. orp.saliotr. will do iE rclt lid tE dodw is mt <br />ifl.d oi of.rcd to. sl. (36.7044, BNIIB ..d Pmfdt B Co&: 'l'k Conl6.lor'3 LieB hw.b* ml tptl, lo an owNr of <br />lh. pmpsry who ttutds or irpDc rlE6$ aid wth &d o.t m hiNlto, hclf or thm!8h hi or h.r oftaq,hytB. <br />Dovid.d thll sch ioroffir @ mr i drkd orotu 6r sL l( lDw.G,llE hihuu or ir{mEFr i! $ld withi4 om r5r <br />of@rpliaoq fi. or@ Bqilt r win hrw dF tuda 6fpo!i!U ,u h. or dE dii mt t ild or iiprcE lh. pmrsty 6r lh. pu,Fa of <br />-t. <br />rs6wn.r.frh. nofdr, ao.x.lBiEly conlncling wirh licd*d coilEcloB lo 6nqod rt! prcjel (S€ ?044, Bunn.s <br />a Pmtsi'n Cod.: Tnc Conrlrcroa. Lic.nr. La* do( ml apDlyro dn ownn ofpmp.nywth buildr or impmvd rhaon. <br />6nd sho o Ecrs li'rschlmFl! wilh d Co.hcro(s) Ii.mld puls lorn ConmcE r Lic.e Lrw). <br />_l n cxc.rlr unrl.r Scc I &f C fo. rhr rcrn,n <br />WORI(ERS' COMPENSATION <br />DIS.AAAIION <br />I h.r.hy.mrmund.r p.nahy ofp.rjury on. oalh€ tollowiry d.cLBlhtu: <br />I hiv..nnsill,mim.maCenific cofconsedroSclflnsu,.larNorkda.onrpcnsalion,srmvid.dforbysecri.nlT00.lrhe <br />Lah.r cod.,lir rh. r.r,imnc. ofrh. *od( fortrhich rn r€rnrir is issrn <br />I h0vc rnd urtl noinrain work.6 comltdrarion i.odftq 6i rquiEd hy Sdrion 3 l{)0 ofln Lohor Codc. ttr rh. trfomm. of <br />rh. *o for which rhis pcmir i3 ks.d. My wor*d- 66f..siio. iniuhrc. oEi.r .rxl policy numhcr ael <br />42lt?sX o I <br />,b, *n'rr,n", t,* *u***., <br />s 4r ro hcem. dbj6r ro rh. wo*m' <br />wo*6' sm!..slion pmvilioB of S <br />rhc wort for *hth rhh r.mit i. irs.n. I rh.ll ml employ.nyFmn in lny m.n.r <br />mmD.nqrion l.M ofcslifom,.. snd asEc rhar iI I i,Dlld 6.@ft .ubi.rr ro lh. <br />.clion l?00 of thc htnr Cod., I snau. lonhBith &ndy with thos pmvhiotr .. <br />*ARNINC failu,c ro E(:E m&.rc 6mr€.erio. srBa8. ii unhwtul. ond sh0ll $bj.cl coploFr ro diminal Fsllis and <br />iorl da@g.s as p6vid.d for lh.civrl lin.s ull to om hunrlr.d rhonqtul dolhN (5100.000). in <br />lr <br />Cod.. ialcE{ and.tror.er'! <br />ut(lj!]lrlta! <br />I h.cby amrm undcr I'.dlty of lerjury (hil , m licr*d und.r povision ot Chaflr I (wirh S(ton 7fiJ01 of D'vicion l <br />oa thc ausirc$ and Pmfsriotrr Cod.. ,nd dy lic.or. ir in tull for& ad.fect <br />l3 bfiqVlt <br />Co n.lot: <br />c()tsla.l1cltQNt]:Nlllll ;]:N(r <br />rskd{S.r l(r')7, Civ ( ) <br />AIf.l.lCAtrI.ol:OAAAUq! <br />I ho$y al'm !nd.r l,6rhy of p.rjury on. of rh. follopins dtldlions: <br />D.mliri.n Pcmi!-A3b$los Nodncarion l€deBl R.Ful.lio.s(lill.40. Pa 6) <br />R.qut.d Letrer of Not6crrion <br />-l <br />c.nify th.t rhc fcdeBl ErularioB essding rbcabr renohl rE nor rDplicohL lo lhG ,mj.cr <br />Zl cdify rhd t hit rcad rhi! aDp lic.rioh eri slnrc rhd rh. .b.v. inform ion ir oret. I lsrc lo omtly wirh ,ll Cily and Counly <br />.nli n.es rndSlrrc li*srcl n+,crs.nlllir$ ofrhis Cirrdi counry <br />abov. mnrion d lmpcny,or <br /> EDll.rhl or A!.nl Sltnirur.:lt <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Building Sewer <br />Area/Storm Drain <br />lnterceptor/ Clarifier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOUSPA <br />P{rap/Drain Line <br />Main Drain/Pool Piping <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewer/Cap <br />Rough Plumbing <br />Final Gas Test <br />Meter Release <br />FINAL b w,L h;SW*< <br />Notes, Remarks, Etc <br />Back Flow Device