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PLUMBING]NSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Underfloor
<br />Gas-Underfloor
<br />Building Sewer
<br />lnterceptor/ Clarifier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Pipeing
<br />Roof Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOL/SPA
<br />P{rap/Drain Line
<br />Main Draini Pool Piping
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Misc
<br />Gas Servrce
<br />Water Service
<br />Lawn Sp!'inkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />Rough Plumbing EXPIRED
<br />Final Gas Test
<br />Meter Release I ;F.ll : I ZUI I
<br />I a./.l rr(.rl q€i
<br />FINAL
<br />SAM(
<br />O*n.FBu'ld Llc.l rfon
<br />lhcr.by rflim und.rpcnrlry or pc,jury r[ lai]cx.mpr fm$.( onrticroG'Lrcc.lc Liw rorrh. rollow rBr.aor (s.c 70rI 5 B$iicss
<br />and Piof.sion Cod.) AnyC yorCounrr*hichkqlir.salEmtrrocofnrucr.ih.r,,mprov..d.nrLrshorrflanlnyt!rudurc.nnortlB
<br />issurn!c.ahorc!uncsrhcnptlicrmforsuchp.nniIofilc!sien.drlar.mcn,rharhcornrci5]'c.rscdp s' ll.rhcU.rtrorsoirhc
<br />Conrdcrois L'c.hr!d Lu* (C[!pt.r9. Comm.ncrns wnh S..tio ?000olDivt'on 3 oidtBusin.$ntd Prol6nons Cod.) o.rha' h.or
<br />sh.iscxcmprrhcr.ironandth.bsnldlh.allcs.dcx.mpxonAnrviollrionofScdionT0Sl5byldyrPpllcatrrlodp.!,nrsubJcctsthc
<br />ipplc.nt to. cililp.nahy ofnd mor. rht.6v. hundrcd dollm ($5o0)
<br />L rls owtrcr olrhc flolrny, oi nly.nrlnoy..s wirl, *ucs rlt! $lc conrpenslrL"n, q'll d.l[c woiL rtrd dc 9tuct. r D.r t]rcnJe,i
<br />o' .frc'.d lesrl.( Scc 7044. Bu$..s rrd P,oi.seons Codc TECorr'rcr.r't L'c.'s. L!\! J.$ nor rpf \ r,trn u.!rc' ofr[cI'oDen)
<br />*hol)uildi6r'n1tro!.srhcr.on.Jnd$hoJoc!suchxnlh'n$.lloihcrsclforrIlouBl,ln$h.'.uncorpovccsp:ord.JrhJrn'cl,
<br />oD.c'Bulldertrlllhav.rh.burd.troif'fvinsrh h.orslktrol[tr]ldo' mp'o!. r{, rhcl,u,}osc.iil.l
<br />_l, s own.r oirhc prot rly. !m crcl$vcly coitactnrEqLrl liccf$d cotruicroB ro otsntrcl rhc froj.cl ( scc 1044, BsMs Md
<br />P'ofgsion Cod. Th. Conrocroat Uc.nsc Ln* d@r noi !!ply roar oqno otplop.ny sho btr'lds or rmPov.! r[.rcoi. nnd *ho
<br />co rra forruch pojcclr wirh a Cortnctd, licci(d pu6uu.r ro rh. Conradors L'ccfs. hQ )
<br />_l rm q.mpt ud., S.cion
<br />WORKERS COMPENSAIION DECLARATION
<br />I hcEby afiim u.dcr po.lry of plrjurl one of lh. followinS dftldalions
<br />_llrJye rd wrllmlintlli aCdnlicarc olCons.trr roScli.losurc tu sork's .onlpcfra!or.6 r)rov'd.d nn by SudM -r71)0orrlrc
<br />Lab. Cdd.. ior di p.n'mranc. oi rhc lor k lor whrch rhc pcmir 6 iesu.d
<br />lh.v. rndrillmainrai. wo*.rs compensa.oninsur.ic..6'cqu'r.dbySccnorl?o0olrrcLrhor(otlc,lorrh?p.rfomttrcc.idrc
<br />sorktorwhrchrhirp.mil6rss!.dMylork.NconFnsnrio.rnsurr.c.crr'.raidpolicrnum&,r,.
<br />---Erpnca
<br />".2:::,:::"
<br />u1*. ',1*, r. r
<br />nor U. conll,.kd ifrhc r)m isfotOn.hundrcddolla's itL00i orl.s)
<br />rh. r)s'tnltr,rc., rlrN trLrI nf \!rr]r1r rlrr ,trNL,\ $tr(L l\,r
<br />h. wdk.u conpdlalron laesoiCllifmir md rsc.
<br />comnoiarion prcvisiois oiS.ctionST00oftc LNc cod.. t thall.lo
<br />-z-tl- o 6
<br />$ARNING Failur!ro s.cur so,kus' conrpoxallon cov(rasr c.r.r,ctr,iot (,., rir,l t,crr h.rr,\l! \
<br />fi.6 urro on. hunjr.d rho6md dollM {!100,0o0).in.ddirion to rh nsdion, dadoe.r 6 providcd rs rh.Scarion 1076 ol
<br />rh. Labor Cod., int r.srodarmfr.yt f..s
<br />I hc'cby alfim undcr p.trahy of!.!ut rh$ I am liccns.d u.dct provision ofChipr.r c (com I
<br />thc Busioc$ and Prcl6siNCod., and nry lic.ns. k in fullforcclnd cff6r
<br />2-a-oe (..nn
<br />I hr.by.fim undc, p.nalry ol pcrjury rh rhG n r c.hnru.rion l.ndins agcnc, 16 rlomric. ol rh. work for w[ich dris l-tm E
<br />issrcd {S.c ,097. Civ C)
<br />L.rd.r's Nam. __
<br />L.rJ.rs
<br />^dd'.$
<br />.TFPLICAN 'S D}]('LARAIION
<br />D.'nol'r on P.'mirs aib.sros Nonfi!rnon Ii.d.'nlR.3rl ons l anlcau,I'ut.)
<br />_ R.qunld L.rt.rDlNotific on
<br />ad,
<br />$at lhc lcd.r.l E8ul.non! rc8irdirg6b.nc rcm.ral E c
<br />rh.tl hNc r.ad thB.pDlicauon andnlrc rh rhc
<br />ntu Couniy rr cor.r upotr rhco;dinmc.i aid 9 . Lres rchritr8 ro
<br />ibov. mcnto..d prop.dy f.r n'rpet w;:*
<br />Pcnnirr.. nrm. (dinrl ,<_---'-
<br />a--1-z-'*o(
<br />I
<br />Dr. _ O{n.'
<br />Policy Nombd _
<br />Area/Storm Drain
<br />Notes, Remarks, Etc.
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