Laserfiche WebLink
PLUM BING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS (xvNER BtJll,lI,)R l)l l.cAl{A I'l()N <br />rpplicililt'orrpcnnitsuhjcctslhc applicnntkilcivilpcnxllyol'rxrlilt)rclhdnfivchun(lrr'(ldollilrs(55(X)). <br />_1. a\ os'ncr ol thc pfi)lrrty. or nly crnpl()yccs rvith srgcs r\ ll)cir s()lc coilrpcnsali()rl. Nill&) lhc lvork at(l lhc slrlrclurc i\ nol <br />thc pn,lEn) s'ho huil(l\ or inrrorcs lhtrr\nl. arrl s'ho (l(rcs such rcrlk hinrsclf or hcr\cll r)r lhrough his or hcr oslr cmployccs. <br />srlc l. <br />rnrl *ho conlract\li)rsuchprcjccl\silhi(iililrrchr(s)liccn\cdpur\uailllolhc(i)nlrncloa\l-iccn\cl.rwl. <br />-l <br />um cxempt undcr B. & P.C- for this reason. <br />l)al. ( )rr nt. <br />UQBtrEBLIIIMPJNSAIIQN <br />DECLARATION <br />I hcrcby il[firil undcr pcnulty of pcrjury onc of lhc ltrllo* ing dcclaratirts: <br />_lhavcilBlwill tnrintriiaCcnillcatco[ConscilthSclLlnsurcli)rsnrkcrs'conlpcnsalitrn.as pmvidedforbyScclion-17U){)flhc <br />l;rtrr ('odc. lirr thc pcrlbrnuncc oflhc work lirr which lhc pcrnrit is issuctl. <br />_lhavea[dwillnuitrltinw(,rkcrs'conllcnsatiooinsurrncc.as rcquiledhyScclion-37{X)ofthcLsborCodc.forthcpcrfornnnccol' <br />thc work lor which lhis pcrmit is issued. My workcrs' conrFnsalioI insurancc caricl ilnd policy nurnhcr arcl <br />c**, Z.Yitznr+zr.ce oF Tt*; lJgrT /, /rnPolicyoo <br />)Cl ccility lhill in thc l)crli)nMncc ol lhc work t'or which lhis l)crtrril is irsuccl. I shrll nol cilrfk,y nny pcrson ir any manner <br />WARNING: Failurc lo wure workers'comJEnstion coveE8c is unlawfirl. lnd shall subjcrt an cmphpr to aiminal Fmllis and <br />civil fincs up to orc hundrcd thousand dollss ($100.000). in addition to lhc cost of comJEnstion. damgcs rs providcd for lhc <br />Sectk)n -3076 of thc inlerest and ulkrrrey's fees. <br />*rn-,,, 4rl /44/nt k! !t/P €t/4 ztc4z <br />r rcnissn conrnarTotW <br />DECI.A8AIION <br />I hcrcby alllrm undcr ncntlry of pcrjury lhut I anr liccnrd untlcr pro!irion o, Chaplcr 9 (cotrnrtlcing s'ilh Sccliil 7(XX)) ol Dil ision .1 <br />r)t' thc llusincss rDd Prrlissirns Codc. atrd mv Iiccnt is in full lorcc dftl cffcct. <br />3c )>r7L/7LiccnscNutrrhcr:kt Hec <br />CONS'TRUCTION I I.'NDiN(; AGENCY <br />i\sncd (Scc. -1097. Civ. ('. ). <br />trndcr's Namc: <br />knd$'s Addrcss: <br />AfILICANLDECI.ATAIIQN <br />I hcrcbydninnundcr pcnalty oIpcrjury uE oflhc folk)wing dcclaralhn\l <br />l)cnx)lithn ['crflils-Ashcstos Nolification [;cdcrul Regulillkus (Tillc 40. Ptrf,6) <br />-Rcquircd <br />t4tlcr (,f N(ililicdlion <br />-l <br />cenify thfl Ihe fcdcral rcEulalions EBEdinS asbcslos rcmval sre noI applicahlc to lhis pmjcct <br />_l ccrtify thal I harc rcild thi\ irpplicilti([ in(l \lutc lhat lhc xh)\'c iDli)nnxtion is cofcct. I agrcc lo comply wilh ill Cily rnd Counly <br />ordinarccs and Statc llws rclating to building construction. and hcrchy oflhis City and County lo cnlcr upon lhc <br />rtnvc rrcntioncd proJrcrly for iospcction purp(tscs. <br />.\ppli(ntrt or Agcnl I)ale: <br />Pemlte Dame (pritrt):.-lo occ a)+,/- <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />I nterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rouqh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />lVain Drain/Pool Piping <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 />F!NAL z4*.2t2,t J)e,[e #€D <br />Notes, Remarks, Etc <br />\. <br />l)illc;