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PLUMBING-INSPECTOB BECORD
<br />APPBOVALS DATE ID/SIG.COMMENTS OWNER AI]II-DER DI'LCARATI0N
<br />I hcrchy rtltn unJcr p.nrlry.l Ntury rhd I anr.xcr.pr liom rh. C.nLrcnn Li.cn{ ttrw tbr rl'i- ,i,ll,,sing rciv (sc.?(r1l5
<br />Bu\iric\\ trd Pnnision C,(c): Any Ciry o! Counrt *hich rcqonc\ n Fnnir ro dnr{ruc|. ulr.r. mprirc, dcmlirh or rcBfi oy
<br />srru.rurr. priorro irs issusncc. rlso rcqut r rh. lprli.rnr l.r !u.h Frnil kr lll.r \itn (drcif,trr rhd hcor shc is lircn\cd Pu^trmr
<br />r, rhc !n)v^i(,N ol rh. Cotrracroi\ l-i.co*d lr* lchrprrr 9, Connnc .inS qirh S.ciion 7fil0 of Dilnion I ol rh. lltr\inc$ rnd
<br />t'rol.s\iflrsCodc)or rhrr h!or\h. isctcn{ rhcrciiorr rhcb0{i\n]rrhcrllcgcdcrcnrfl6n. Anyvnn n,nolSLtrt,nT(,ll5ht.try
<br />:lp!li.rtrr turJ Frinir suhlc.rs Ihc ifplicnnl lo rcivilpcnalrrolnor mdrht nvchutrdrcddollttr\lS5lI))
<br />-1,
<br />&{ osM of lh. ,|.Fny. or mr.rplortc! wnh wa86 &r rlEi $lc oftpcnslioi. will &' dE e*.,n Itl slnrre ii Dl
<br />inrcnd.d oroficRd for sk (Sc.7041. Busimss ed PrDfdsbnstuq Tle C.nleror's Lic.N t *drcsmlarptytouowol
<br />rlE pmFny who builds or i,rpmts tlisll. .nd wlb dca sch rcd( hinsclf or n ,*ltor rhbu8h hh or hd own crrlpk rfts.
<br />Dbvil.d rhlt suct iE|mwEnc I ml hld&d do6.itd fD, eL. tl ho*.E 0E hilding or inpiffin il $ld $ilhh om Jqr
<br />ofotrpkri,r {E olrrcr Builts qill haw ,E hlthr ofFlving tlEl lE or slE dii ml boild or iq,Dk dtc Flpcty tur dE PuqDc of
<br />-1.
<br />rs owrcr of rhc r,!n€ly. !o .r.lusivcly contmti.3 with lh.nsd contia.t,n r. mmdcl rrE Imjct (Ss. 7044. suti*rs
<br />,nd Fbftssion Codci ThcContretols Licenlc Llw dfts.or amlt to o. owncr of Pmtcrly *lE builds or imPorcs lhcrcon.
<br />lnd who ontdcrs for slch pmiels wilh r Conlaclo(s) ltcnscd plBuur ro rh. Conlraclor's Ltc.sc L!q)
<br />-l
<br />ancredfl undd S6rion- B. & P.C. for rhis etson.
<br />!!8TD&i:COM@IAIIQN
<br />DECLAMITON
<br />I h.Eby affirnuder peiolryofpBjuryoe olrn followinS dclaalioni:
<br />-lhrvc
<br />trilln nrlifrC.nifKtrrcofcotr*nrtosclf.ltr{trcld*orks^ onrPcrtnridr.as I'r)rincdntrhts ridr:l?(x).lihc
<br />Lahor Gxtc. (r llE pcni,rrrxrft-c ollh. *ork f{r whi.h rh. t,cnni is i\sucd
<br />-lh0vcond*illmrinrainso.isco,rn€Nlrioninsuramc.asrcquir.dbySerbnl7mofth.bbortuc,forIh.0.rfolr:wcoflhc woi( for which rhi\ pctnl is i,su.d. My wortm onDcnsslion insudc. .mLr ad ,olicy numbo e:
<br />P{ric, Nrmbo:-EiP
<br />-l
<br />ccnili rhat in rhc D.rfdrmm of lnc wort for whicnlhh pcrnil k i$!cd. I sh.llml cmploy 8ny p.Mn in oy Mmr
<br />!o sro h(otr {brcr ro thc worl6' sdncn$l,nn l,$r ol CililnmE snd lErcc lhsl ill fould bc.om obF' !o rhc
<br />wuAcN mmFnsaion pm!isions otscdion 1TOOofrhc tibm Codc.l \hau.lonl *th cdlhly *rh ltrc pFvrhn'.
<br />WARNINC: l:{ilurc ro $curc workcn o'npctrs iotr covcflgc is unln*iul, rnd shill rui'lc.r dr cnrtlorr lo lrn ndl Nnrlras lnd
<br />.ivil ftrs np h otrc hlndrcd rhors,tril dolla^ {Sluo,000), in rkldiri{nr lo rtu.on or.o r]rn\0rnnr. d!trusc\ as ptuvtrcd rhr lhc
<br />sccrnr 1076 olthc Lrhtr Cdlc, 'nrcrci and anoaryt lics
<br />IICENS[Dj0N:I3 crA,U
<br />II,CIdBAIIQN
<br />I hdrcby !fin uNl.r pc.rhtor rcrju.y rhar I am li&n*l unds lnivilio. oi Chaplcr 9 (cuNmtunrg wnh selion T$lDotDivtion.l
<br />.i lhc Blsincs lnd Pn, r. s\ ions Codc. .nd mylicctrs n in tull nncc DIrl cr,..r
<br />CANII8II:IIaISIINDINGIGENII
<br />I hcEbt affrm undd pcMlry ot p.rjury lhd thcrc is a ointudhn tc.dirg agcey for tt PcrfolrMe of $c gtrt for whi.h llis pemil is
<br />isura rsN 3{|)7,civ. c )
<br />AITLLCANLDICIAB.trUq!
<br />I lihity illnn u.dcr petrrlly.ipcrjury orc orrhc n,lbwinE dc.lmrnrns:
<br />DcnFlirion Pfnirs Aih.no\ Nolilicalion FcdcralRcEullri(,.\ lfirlc 41). P,n6)
<br />Rrquircd trn.r of Nor ifi!$ion
<br />-l
<br />ccnify thd llc tcdcdl EgrLrion. rcei,{ii8 asbcslos rcmvol @ nor q'nlhabh lo this pmict
<br />I ccnili rlur I hxvcrclld rhi\ rypll.rri,rrnd q!icrhJr rh.rh)!c iikmrrior i\corsr lrsrsi'.. rrly$nhtrllCirynndG)!trry
<br />onlinrn.r\ r d shrc liss nhrins ro hull{llns coo(tucrion- nl hcrhyrurtrrizc qnc{lllrlivcs oirhi\ Ciryrnd Counly ro cnl.r uF)n rlt
<br />inc lrnrirncd nop.nt lbr n,\Fdnnt Nrnoscs.
<br />ApplicsnlorAae Si(nrlure
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Buildinq Sewer
<br />lnterceptor/ Clarilier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Pipino
<br />Rool Drain
<br />Tub/Shower Test
<br />Rouoh 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 />Rouqh Plumbinq
<br />Final Gas Test
<br />Meter Release
<br />FINAL :zrt)
<br />Notes Remarks Etc.
<br />Area/Storm Drain
<br />4liltr
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