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ID/SIG,COMMENTSAPPROVALSDATE
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Buildinq 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 />Rouqh Water Heater
<br />POOL/SPA
<br />P{raplDrain Line
<br />Main Drain/Pool Pipinq
<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 />Back Flow Device
<br />Rough Plumbing
<br />Final Gas Test
<br />I VL., ),/x) t)lFINAL2/t
<br />r)\\ \EIl llt ,Dt,:R t)t l,(,\R Il()N
<br />I htrcby amnn trnd6 lE ahy oipdju\-, lhd I on.\dn tio,n rhe c.nt.doB Licos tiN for lhc
<br />'ollo\ins
<br />rc'en (Sa70ll5
<br />B sinss ond I'rot6sion ( odc): Ary Cirt or Connry shich t&luir.s a Pcrnil lo co.slru.1. ahd. impovc donolish or EFn ev
<br />so.lr., r{i ro irs issrMcc. eho rcqriG lhc q,ali.dr lor $(h Deflni ro filca sisncd srar.nenl lhat hcorsh' Li licc6ed Ptrm'nl
<br />lo llr lro'isioN .f lh. .onrrlcloi' r,icms.n Lav (chsplcr s. (-omm.acing \riln serion 7()00 o. Division r of lh. Irurin.rq and
<br />rrore$ioft cod.) or thil lE or sh. ! .\.r.pl rh6.6o,n inrl rh. b6n tu rh. .li.sd crmFioi. Anv violarion ol sarionl ol I 5 bv anv
<br />etliL.nrlorApmnsubj<rslhertllicanlro!civilpc.ah).lnornucrhann\.htrndrcddollaF($5oO)
<br />I. s o$n6 ofrhe prcpo1) , or my crDlqs r nh $086 as lhcn $b coDpqsarion. $ ill do lh€ \ orl md $e srn'crrE is not
<br />ido .n oroftdd fo;;k (S( 70.u. Busin6s.nd hot6sions (hd. l1r. Coilra.k s ti(6* li\ do6 nor Epdvh an o\ns ol
<br />rhc p&I{ny \lFl ildc or ir.pR\ 6 rh6en. ud \ hu &6 nr.h ro'l hins.la or fios.lf or nnoush hit or h'r o$n ''nPnrv6*"'.r.a,1"..r, mmtdMh@ft rtsdat or onsd iir elc. lI ho( d d rh. h^rildin! or mprovordr is $ld sihin on' )6
<br />;r(ornpldNn. rl'c(i 6 B il.l6 \qllhi\. rh. htr(kn or|rrsng rhd h. or shc di.l d hrild or iiltor. fi. Plspdr,
<br />'or
<br />rh' plrD'*'l
<br />l. 6 o{n& of rlE rmFgly, an .x.losivcl, conrracrihs $ nn lito$d .odr.doc lo Nrchl.1 rh€ rrjsr (sd ?0 . Btr{'t((
<br />;ii lbrasim codc, Th: (i,nlractor's !.iccnsc l-aw dos nor rr,plv ro an osnr of Prc!.n v rYho hoilds or impoverhscon
<br />and Nho .onta.1s for $'ch l}oj(G \rirh a Coni6do(, liccN<l !tr6o.nl lo lhc Conrmcrois Liccns' t-as )
<br />I ancrcnrpl u.d.rsdiM .tt &P( for lhis r€a$n
<br />woRKrqs' ( onlPENsaTloN
<br />DECI.dIAIION
<br />I hd.by amrn u.dd podlyofpa.juryon.oarhc lollo*i.s ddhnlioG:
<br />Iiovcdd*allmaimiin.Ccnifi.lt.oa(oNntlos.lfln.forNorkosconpqtsllion,spllvid'dforbvSeltun3700ofthc
<br />t bor Cod€, for th. pGfomdcc oflh. $t.t for \iikh lh. Fnnn it h3Grl.
<br />- l h$. and will naiolai! \'orkcu codp.Galion tuuEnce 6 r.qon.d hv Sttion l?OO of lhc ltbor Codc. for ih' 0drnmanc' ol
<br />rh. {oik for trhth rhis Fni n L$u.d. My *0116 comPsMlio. irouranc cari6 dd Policv nurbd dc
<br />cui6 , €*e11lT
<br />EipiEs:L
<br />{.di"nnr,n, u'
<br />'n. -a,Dan.. orrlE $ork ror shich r[is l,srnir is hs(dl. I sfiill nor drrplov anv pds(n io
<br />'nv
<br />ri'n'r
<br />m r t, tnonc rurlci t rtrc "!r k6' co'np.nsar io. la\rs ol c.liaonri.. and asre rld il I should hc'ore $hj(l t' rlt
<br />\$r[ql co'nrEnsiinJn lrorisionr.fscdn,n:r700 orrl't Ln&'r Code I nh.ll fodfis ilh conplt $ ith rl$* rovisios
<br />(tril
<br />'Zo 2- o 'fip Pal;<t
<br />l t( tiNstlD (r)N I ltr( l()R
<br />DIU.dll:!!&]
<br />thd!b}a']inntrnder,mlllyofpqju}lhaltrticeis.ntriddttroltioanl(.llaueI)1c.m'ncNiljs\ilhs(lionTl)00lofI)ilki.tr1
<br />oa r1r llosi.Gsan(l Pr.fsions(od., a,il nlr li.cnse s n finliolcc dcfli.r
<br />.o*.,*,,- e -3tp l-ictuc Numbr B3o5w(
<br />-,", o r f N llOza c-,"*".,X Jn .aad o*'t- D{-- b,}+--
<br />colllalrclloNlrlll.lNc-acElgl
<br />I heEby.flirnundd p.nlltyofp{juryOd lh@ is;.eru.rion lodins!sd.v for lh.patomsc'flh'{ort tur\ ichlhi!Fmh b
<br />bsu.d (s(.109?. Civ. C ).
<br />APPLICANT DI!('I,ARATION
<br />I nodt.lfmundd poahy ofldjury on. olrhc foll.Niis d(lar.rions:
<br />l).molnion Pdmirs- sbdos Nolilicalion F.d.rdl R.sultrrions (Tilc 10. Pan6)
<br />Rcqoircd L.lld ofNo ij.aion
<br />I csrily lfid rh. Lddl r.subtio6 egrdi$ sh6lo3 6o!tl n. iol a$,lttbl. lo fiis pnj..r
<br />@ cdiryrhar I h .,eadrhis.plltari
<br />ordimn.6 and SIal. k$s rckli4lo bui
<br />abov€ Ddlion.d pft'p<ny for icp<iion
<br />on ad srdlerhar rhc.hovc infonntlion is cond I agre to corplv Nilh sll Cilvand Cotnl!
<br />lding comlructi.n, &d hdct y aulnor;c rcpre oarhirCiry tud Counltlo o16 lFlnllE
<br />Applic.trt or A!.nt Si*trrlur€:
<br />i:rr aA
<br />bzo
<br />Notes, Remarks, Etc
<br />PLUMBING-INSPECTOR RECORD
<br />Gas-Underfloor
<br />Meter Release
<br />Cod., inro61and dtom.y s fB.
<br />pn-rr* n,." rp.rno,2!-'[ ild
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