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PLUMBING.INSPECTOR RECOHD <br />COMMENTSAPPROVALSDATEIDiSIG. <br />UNDER GROUND <br />Waste & Vent <br />Water-under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />lnterceptor/ Clarilier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rouoh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />Main Drain/Pool Pipino <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Miscellaneous <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewer/Cap <br />Back Flow Device <br />Rouqh Plumbinq <br />Final Gas Test <br />Meter Release 1 ,/ <br />"h*l11lt?.Tlvvtt-tt <br />Notes Remarks Etc. <br />on'Nlti Btrll,r)riR trut,('iRATr()li <br />I ncrchy rfirn undcr pcnxlry .r F..rlury rhnt t ar ctmp! rn,n: rhc Co.rrr(trs- I-iccn* ljs r(, rhc follo*inc rcrqrn ISN ?0ll 5 <br />Busincs\ rxl Proris\n Codc) An, Ciry ot C.utrry whi.h tu'qun.\ r Firnil to .onitu.r' nlt.r. impnrv'. dcmohh nr mnrn Jnv <br />sn,crurc. ri.trt, irr issuincc. llso rcaunc\ rhcrlPliclnl li,r \u.h Finlil ro tilc r silicd srnrcmnr rh h.or shc is liccned put$!trl <br />ro rhc fmvision{ of rhc Contrcttr s l-iccn\cd ti* (Chrllq 9. Con icnc rS $irh Sccrion 70m oI l)ilhnrn I ol rhc Bnrii'ss rnd <br />ItofrssionsC{.)orrh{llorslti\crcnurhcrlio'nrndrhchrsislbrrhcrllcBcdctmplion Anyvn,hriotrotSc'rion'0]15 hy an, <br />rppli.afl rnr a pcnnir \uhj..rsrhc lpplicrnrro r.rilpcnrlr).lnol nn,rrMn ivc hhdftd dollnrs(55@) <br />-1. <br />!s osn.r ol rh. tmllc y. or my .mph)tccs silh uSc\ r\ rltrn $k oNrcn\ari( sill do lhc $dk ,kl thc ( Mlu. i{ tr r <br />inrc cn d off.rod ln; sic lsN rol-r, auircss lnd ttDrc\\i{,is C(i]c: l'hc O,nrn kr I Licn\c l rw docs nol r,'P'v ro 'n otr ncr or <br />rhcrsncn) who huild! or nnpBvt\ rhcE)n. <br />'lrl <br />wl$ doc\ {ch wrl hi'nsrlf or h.(.ll.r rhtuuAh his or hir oqtr crnplo}cc\' <br />p","a"A rrru.r.rr iqriolcrEnB irc nn inhtoLd oroficrcd Lr $lc ll ho$csr. rh. t{ildin! or nnpoEnrnr i\ {nd wilhhonc FT <br />; co'rlthrion. rhc ow;r Buiklcr lill hir rhc lnrdcn oI pR,viru rlu lt ot \hc dil n truild or iqr c $c PnrFnv tu rhc PurF)s of <br />I. asosns.ilhc pmPfnt. rncklusi{lyconk il8 wirh licc.scd coikr.k,R k' .oi{tuct rhc nmlNl lscc 7014. Bx\i"c* <br />lnd Pmls\i{)nCudc:Tnc(onlrlcktr\l,i.ctrscL.$docrnorrprlyk,(no$trc'orpn)Fnvshobuild\ori'nnrcvcsrl[rcun' <br />!d qho conrrh lor \u.h pmj.cr rnh a G'nbrrdn e lntn\'i Porunnr t) rhc conrrrcttr\ Licctrs I !*) <br />l.nrcxcfirlrundcr Sc.riotr- B &f (. turihi rcrsor <br />_ orei- <br />- <br />-rdt <br />BrEBecotrjutAnoN <br />DECIAEAIIOtr <br />I ncrcby afiirm undn p.Mlly of ,,6jury om ol lhc lollowitB dnldarions: <br />-l <br />ha\ftJri will trinrain a Cenifrarc or Consnl ro Sclfln{re ror workcF .onr.nsolion. ,s prcvid.d lor bv S<rion 1700 of ltc <br />Libor Codc. for lhl Frtomncc oflhc woik r.r which li. !soi! G issucd <br />-l <br />haE lnd sill mainraitr workc^ c.mpensarion insurrtut s\ i4ltcd b, Sc.riob l?00of lhc ljhortuc fot rhe p'rfolmre or <br />ir$cd Myworkcn conpcn{rrion nNuramc udi.r rM P.licynumh.rd. <br />-l <br />c.d ili rh.r ir rhc pcrl'orroNr of lhc sorl lu *hich Ihi\ |*.nir i\ isskd l shrll nrr cnrpirv ,nv lcnon itr rnv mnRr <br />w, ns ro hccom \ubhd t, rhc q orkcr' o'nl,.n\dion lrss ol Cllii.rnir. nnd .8rcc lh irI shotrld hccom subjcct lottE <br />{orkcN c.mpcnsrion pmlisn,nr ol Sccl i{,n ]TOO of ihc klior Cqlc ! \hnll forrh*irh ..mlly enh rhrr p$vnions '( <br />WARNIN(;: F3ilnrc ro yclrc $DrkcF $mpcnsitio n erduge h u.lawtul ud ihnll subiccl u cnplo)tr lo diBiBl F,,Xi3 aid <br />b.* htrndrcd rtn,usi.d dolles rSlm.OUO), in sddirion ro rhc d!roBcs L\ Irevid.d for rnc <br />I hcrchv rrrirm und.r D. nlry ollrcriuryrhd I dn li.cnql;nd; !n'r'\nr olChJPrcr 9 (r.mtrtrn.ins sirh sc'rir't ?oOJ) I'rDn1\nr l <br />or thc llu\inc\s dnd tnnts\i.rEc.dc. rnn nrrliccn.c ii ir tullldcc uxl;llc.r <br />rl -zt-<?,0 <br />rtgn-r* <br />I hcrcny dtum undq pcndlly of p"tjo,y rtrn rt "* i*.mninn iendirg !8cm, for fic pdlormrcc ot tte w'rk for which lhis lrrmn t <br />Llnddt Addcs: <br />APPI tCAlYT NT'CLARATTON <br />I horq atrm !81c. pcn.lry or Frjuy orc or 0E rouD*irs ddl@rions: <br />D.mlirion P.rmhrAsbcalG Nolification Rdc,{l R.Sulalions (Titk 40. Pan6) <br />-Rcquir{ <br />bll6or Noriiqtion <br />-l <br />c.niry rhd th€ fedcrul ,cllhrbns rc8lrdins $hc\ror tfr)v,l !rc nol +pli.ohlc lo lhis !nj.rr' <br />-l <br />ccnify rhar I h.lc rcd lht aptlicalionmd stalc lhal $c ah.!c infonmrion is cotrccr' I a8re ftr complv wnnallCnylnd Counrv <br />ordimm.s Md Srar.li*s Ehlii8 lo <br />lhovc mnrion.d fotcny for iost c' <br />ho.izc rcrre$nrsrivcs of rhk Ciy and <br />Aprll.lnl or ag6l SiENlu s.2 <br />Gas Service <br />FINAL <br />isGrt (Se. 3097. civ, c.). <br />L.nd6 s Nam: <br />-