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ID/SIG.COMMENTSAPPROVALSDATE
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Buildin Sewer
<br />Area/Storm Drain
<br />lnterce r/ Clarifier
<br />TOP OUT
<br />Waste & Vent
<br />Water Pi n
<br />Roof Drain
<br />Tub/Shower Test
<br />h Water HeaterRo
<br />POOL/SPA
<br />P-tra rain Line
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Gas Service
<br />Water Service
<br />Lawn rinkler
<br />Sanita Sewer/Ca
<br />Back Flow Device
<br />Final Gas Test
<br />FI NAL
<br />()\1Nt:R tlt ,DnR l)+:1.( ,\R,\ I l()N
<br />I hddr am,n ud6 Doalr! of pBilry lh.r I tun crcmpr aron rhe cont.clos l-icds. l-as' for lnc
<br />'6lkNns
<br />(sn (s't7011J
<br />Uusinss snd Pol6sion Cod.) ny Cirt or Coxmy shi.h requn6 6 Ffrn r. conrrud 'hc. impoYc dmolhh ^r rcrin anv
<br />slrucruts, rior ro ils is$'an.c. Ako rc(lut6 lhc spplitml for su.h lfnnn ro filc a sirncd srihol lhar h' or slE h licm'd PUBBnl
<br />lothcPo'isiois.flh.conlraclfi.sr-icmscnLa\rlchlpldl).(-omncncnl!\'ilns.tlionT000olDivision]loflh.Rusi.*rand
<br />t'rur6sioncod.)orrhalh.orsheis€tcmplrhftaionandrh.t\Tisrorlh..llcB.ncxenfli.nAnvriolarionofs'rltun70'rltb)lnt
<br />rt)|1li.anl fo! a ponir iubjc.klhc apDlicanr r. tr.n'ilpenaht oi.or nor.tho fivchundrcddollac(!500)
<br />l.aso\tdotrneprcrsly,orryc,nPlovt6\vilh*i8.sasrh.n$k.otr'pensalioi,\rlldolt'sortstullh'nntrlr'Gnor
<br />;rdd.n M ofrd.d for ele l ss 70.11, ltiBin* od ProfBsnns (idc 1h. ( od.acrors I i.os€ l 3N d'G nor apllv n' an 'tr nd oI
<br />rhe lrR)pclr \rho h'ikk.r ir.pro\ 6lh@n. and $ho dG {d so'{ hnns.lrorhcs.la.r rhrcushhis or ncr o\n 'mplot'6-p",,a"a rmr o.h L.pro\.flcns a,e mr inrdit{ or ofl'6.n irr sl. lf ho\r.6. lhc buildi.! or inlpl ovmdr ir $ld silhio onc vd
<br />;r@mtldion. Ilrc (.hrN Bui!:td $ ill hnr€ lh. htrdd oitr$ ins $at h. or snc dil mr tdld oi inprort lfic lroldr lo nc !r[In* of
<br />l. s o\!ns or rh. p' olElr. arn €xchsn.l) conracl ins \rnh lic.nsrd conltadoR tu .onslnld rhc pmjd (Se 7o{'1. l"'rin6s
<br />.nd hlferi('n (bde::l h. Conlra.h's Licensc l.aN dos n.r applYlo 3n.\rncr of p'ol.dv {ho buikh or nnPro\6 drdcon
<br />and \ho conlcds lN strh p.ojds\ir[. ('onrmcl.4s) Iic.dkd PuGuMr torh. (nntr.dois l-i'ce I-a\)
<br />I m.\e l,l und6 Sccrnn . I] & r ( hr rhl' rcis.r
<br />\I()nKERS COIIPANSATION
<br />DECLA8AIIOT
<br />I hs€by rmrm ufld6 lqtrlltofp<juD_ onc otllt lollowinS dda,llioB:
<br />Iha\.EdRillmi.i6t(.dificalcoac.n*nrroS.lt_lniur.aor\orkcscomrd!0rion.sPovid'diorbvSerion1?00ol(h'
<br />l$o. C.da aor rhc pdtomtnc. ofln $o* tor N'ilich ln Fmil is su.d.
<br />7< Iha\.0trdNllma'iti'i\o 6 co'nr.Barion iNuritrcq ar rc{Pir ed t'v S<rion 1700 ol lh. labor Codc. for lh' psfoduc of
<br />-'h. s ork lm tr l"ch rhir p.flnir s is.d Vy {.rk6 comFs.r '^n
<br />i$nmnc. dir ad pnl'q nu mb'r dc
<br />(.,,,., g-ar-1 9'crlJ^. \,a {,rl- (--
<br />n,^.*",u" 4$- o5S h-rt- c) - \ 6 ,,,.-'))r )o"
<br />v, as r, trto.".,l,Bit rhc " ortor co rr)rnsiri,n, riss.r( xrri!iLr. in.li!'( rlrr irl slnrln l{nnne sur'iN( ro rlr
<br />WARNING: [silu.lo sur. trortG ompmelion covdrs. ir mlarrtul. nd sh.U
<br />civil finB up ro oo. hundt.d thoMd dolltB ltl00.0tx)). in tddition lo $c 'oc
<br />ol
<br />nployg k, Gilninol psultlB
<br />^ndd@g6 s proidcd for lh.
<br />sGrion 1076 olrhet bor Codc. iola6t dd.tlonEy s lc.3
<br />IIIITAEAI(}!
<br />I h.Ety .mrm undd p.naht of psjury lhar I m lico*d und; Fotision ol Ch.prd s (commoci's lvith Sccl ion 7000) ot Division :t
<br />.l rh. BusinN and ftofesi.ns Cod.. Ed 'n) licdrs. is ifl full for.c.nd .iTecl
<br />I'cdrsc('lots ADi,. r lrL l?a c-r-.*-k6ar,Md-d<,2.n t V^(
<br />calsr8llcrloNrENDllc-ac[lc!
<br />I hd d,y aftd undd Fn.lly ol Fju.y rll'l ih; is a cocrrudio. lodins ago.r. for lh. p6tomMc' 'f lhc q ork for $nich rhis Fnnn t
<br />i$!.d(S(. 1097, Civ. C.)
<br />APPLICAN'I' t'ECLARATllTN
<br />I lElby alln. undd p6mhy ol Isjury o..ofrh€ f.llo\ins ddlmrnros:
<br />Dcholirnrn Pcmils-A.hctos Nolilicalion r-aldal R.xtrlalions frnt 40, l'an6)
<br />Rcquircd la(d ol'Nolilicartun
<br />,-l csr iay rhar lhc t i6!l r.lul.tiois Elading 6b{stos rmo ac nor .ppli.aue lo this prej<1.
<br />iryrhsr IhlL.r..drhBrpphcsri.na sdcthaltheit$!.io( h corel. I og€ lo comply with tll c y.nd Colnrt
<br />ind sr ar. k\rs reld ins lo buildins codrru.tion, drd aurhord. rcr6qux\6 ofrlns Cilv dC.qnll r,drcup.
<br />, 1,1 \rz_odbo!. mdrion.d propoly for iNp.dion
<br />rDDricnnl nr,\st l shnalu'ei
<br />G <Ag<q
<br />Notes, Rem arks, Etc.
<br />PLUMBING-INSPECTOR RECORD
<br />-,. i ))\\'z.o
<br />5f6- (
<br />Gas Pioinq
<br />Ir4a in Drain/Pool Pipinq
<br />Rouqh Plumbinq
<br />Meter Release 1- /
<br />t I DU/ j "l- PH,?/tll
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