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PLUMBING-INSPECTOR RECOHD
<br />APPROVALS DATE ID/SIG.COMMENTS oWNl]R NUILI,,ER DIiLCARATION
<br />I h.rcby nafinn uDdcr pcntrlry.l Frjury rhlr I m.rr6pr lmnr rhc Conrrlor'Liccn* L(w n rhc r.tn,trins rcavnr lst.70l5
<br />Bu\ircs . Pror.$n,n C(xh)r Afy Cily or Counry whkh rrqutcs ! pcrmil ro onrlrucr. ,ltcr. nrfiovc, d.nhlnh or Eplii rrry
<br />{ncruE. priut ns t*urncc. "l$ rcqriE\ rhcrp0li.anr,or su.h!.nnir ro filc r sisncd dlrcnEnr rhar tEnr shc is liccnscd tuBU l .
<br />n, nE @virn r\ or rlr Conrracrois Licenscd liw (chnucr 9. Co',mcncins $irh Sc.rior 71x)0 dr D'vi\nrn I or rhc Btrsincs lnd
<br />Pnrfc\si,)nr Codc) or rhor h..r\hc i\ .rcq)r rhcrclmn and rh. Ersis lar rh.lllc8cncxcDprion. Anyvi{rhtion lScdk[701t.5byrn,
<br />arplic0 tu d,rmrir \rbjc.h rhc appli.anr ro r.ivilpcmxyoinor m.rcthln livc hundrcd doltars (S5m).
<br />-1.
<br />a oq( of llt pmFnr. or my c"q,loyer pnh *as6 s lh.ir sk omFNlior. will dr dE e* and dE sdEr@ k bti ond or ofi.rcd for el. (56 ?044, Alsituss ed ProL*jons Codc Tlrc Controcrtr s Lt.M tiw docs @t .pply lo u owncr of
<br />lh. pF,r.ny w,[ hildr or iEFo6 tlE@tr and who .lo.s sh mrt hirelf or lEetf or rh(udr hir or h.r o*n chptoln!
<br />l,hridcd thol su.h inllbEftnN@ ml intcricd oroltu ao$h.lf, hosq. Ur huildin8 or iqrowEnr i. $U wirhin ore FqoamIphlbtr tlE Owmr Blildcr w h.w tlE h,n n olFtroving [d tr or dE dn d 6ild or inp6* dE po!6ry fDr rlt porr(rc of
<br />-1,
<br />as owrer oalrE limntny. .m d.hsivcly o m.linS wirh li.cocd conu!.roh to onsrMt ltr Eoj.rt (Ss. ?oat. Busms.d Etrcsio Codc: Thc Coolr dol s Li...* Law do$ mt lmly to un owncr of prcp.ny wh. buil& or inrows th@on,md who ortdcrs fo. su.h nolrri wnh a Cofunctor{s) lic.Nd plr,@r ro rhc Codrsrots Lic. E L!w).
<br />_l a crcmfl undcr Sccr a & IC ttrrht rcson.
<br />uaatrESs:toMfasallr]!
<br />DECI.Af,AtrON
<br />I hceb, rmfln undcr p.mhy of trjury onc of rhc toUowins dRldalions:
<br />lhrvcrldsrllnrdrirtrC'cni,i.ddolC.n\cnrr)Selllisurcnnwork.rrcompcn\(nrn.J\t(rvid.dtirrhySccriotr.lT00ollhc
<br />Lrhn CGlc. n)rrhc FrromrD..nlrhc *or[ lo, Fhich rhc n n ir n n\ucd
<br />I havc lnd *ill mainrain work rJ c.hpenslrion insuruncc, as Rqun.d hy serion l7m 6f rh. Libor Codc. for rhc rrto1mre of
<br />lhis D.mn t isad. My worlst coqrcnsrion inslmncc dEh. a Fli.y nunl,q e
<br />-l
<br />ccniry rhar in lic pdtormsflcc ot rh. work lor which rhn pcnnir n issu€d., shlll not cq)loy any pcMo io any @nci$ !sro lEom subiet to th. m&c6 onlEnsation laws of Cuirumi4 nnd rgft rhsr ial snould hecom subF.l lo rh.
<br />worlcF' compcnsln,n povhion. of S(lion :l?00 of thc bnor Conc, I shlrl. ionhwirh ..nloly wirh thoe p&tnions..
<br />WARNING: Faahrc ro scurc e*cs' conq*nsarion .rwtus€ ir ,nlswtul. lnd shall subi{l e cmployr ro simln l F@[i6 Md
<br />cilil 6ncs ut ro onc hundrcd thousand dollos (t100.000). in lddiln,n h rtc cost of.omp.&nag$ as lpvidcd fo. rhc
<br />Sdn n -1076 ofrhc lrtnr Codc. inlcrc( Md,Jf 1t 2018
<br />tlErlrrxtruaN
<br />Ihc'cbyrllirnundrr F,rdlr, ol lf,rjuryrhar Iam lian$d undcrl)$virn olChspr$I(co nk.nrs*iihSccrioD7(xxr)orDivi\iur3
<br />of lhc llu\incss md Pr)fc{siorN Co{lc. uxl nry li.cnsc i\ in fulltur.{ d.tticr
<br />t9D1?41
<br />C(TNSTRUCA'ION I FNDIN(; ACFNCY
<br />I hcnby aflir'n undcr lenalry of pcqury lh rhs. h a .oNtucrion h.dinB oscrcy for lh. pcrfo.mtrc ol rhc work ror which rhh tnmir i!
<br />iss!.d (Scc. 109?, Ci! C.).
<br />APPLIC NT DFCI,ARAT(IN
<br />I rtnh, rlim undcr pcnnlly of Frjury onc of rh. firbwnrs d(lnrdnN
<br />Dcnx,liri,)n Pe nitsAslrnDs Norifi.dion Fcdcral RclullIions lTiit 4). Prn6)
<br />Rcquncd l. cr.lMnilicdion
<br />l.cnili rhal lhc t dcnrlEeullInnN rcEftline r\h.{,x rcnroval0rc nolq,nlictrhlc lo thh ,)lor.r
<br />Ll ccni,y Ihd I Mvc Ead thh aptilicliinn lnd sIlrc rhnr rlt ahrvc infonrEri'D is cotrcct I asc l0 condy with rlt cir, Md cbunry
<br />ordinnmes and Sr.rc liws Rlnring io hxildin8 consirucri.n. dd h&cb! rdhrnd rcpE\cnrrrilcs otrhn Cirymd Gunlylo cntcr upon rhc
<br />uh,!c rrcnl i(trrd ptupdy r.r in\p{crion
<br />,\lpli(ul nr /\lunl Six. ltr *,JL,N X. 1,. 2018
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Building Sewer
<br />Area/Storm Drain
<br />TOP OUT
<br />Waste & Vent
<br />Roof Drain
<br />Tub/Shower Test
<br />Rou h Water Heater
<br />POOL/SPA
<br />P{rap/Drain Line
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Gas Service
<br />Water Service
<br />Lawn Sprinkler
<br />Sani tary Sewer/Cap
<br />BS!!Sh Plumbing r\q\tt tl&i(Tq
<br />Final Gas Test
<br />Meter Release
<br />FINAL t/LUc 5Dltb
<br />Notes Remarks
<br />lnterceptor/ Clarif ier
<br />Water Pipino
<br />Gas Pipinq
<br />Main Drain/Pool Pioino
<br />Back Flow Devrce
<br />Etc.
<br />P"*ire nane tprino, &rr^
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