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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS (twNt:R BrJlr_rtR DEt,('At{A fl ON
<br />I hcrcnt afiirtr, utrds |rn lrl {,1p.rjory ihrr l !'n.x.nDr lirmlh.(innrrrr|,i..tr\cl-r*,nrrh!Inlhsingrovn,ls.c7l):ll5
<br />imcrurr, pri(tr o ir\ t\!mcc.xhorcqunc\rh{plicanrl.rnrcipcrtrrirrolihrrigtrca$ircnEnr r[d hco! shc n liccn\cd pur{trr.r
<br />n, rhc nmri\ionr .l lhc C ntraclois Li.cnlrd l-nw (Chtrlr$ 9, Co ncNnr! sirh Sccrnn 7(XX) of Dirri( l ofrlf llunnc(rid
<br />r|)|rli.r[turrlrcrn suhjc.rr rhc rmli..nr r. r.ivilrnxktolnor xtr.rhrnfirhtr rddollr\(S5( )
<br />l.nros$ofrhclln,plnr,.rnrycn,pkDlc\*irhsrscsrsrh.nanc.onrt^-n\di(r,.Nilln.rnt\olk rillt {Erurc i\ tror
<br />inlckl.i o.ll.rcd li, elc ( Ss 7(lu. Duiic{s ! d f\ofusi N Codc: Tlr Gnnrrcktr'\ Liccnsc bs d(f,snor rlpl!ki inosicrol
<br />rhc|mlr y sholx,iu\ori'ryn)vc\rhc(rn!.rn,lshod,rrnrhsorkhnn*llorh.rsc)iorthoulhhi(orhcrosncnfloycc\.
<br />nmvi'lcd rhar \u.h npn!$r \ 0rcnn idc'rl(loronircJ ntr sak ll hosrr'. rlrhuildi',gor irnpnn rnr ir oll(irhinon. y!i,
<br />ol'conl0trt,n.rtf, Owtrcr Builds $illh!\c rh.burdc ofr()!in!rharhcor\h.didtrn6uillori'q,rovcrhcpmFntlirrrh.purlxN.or
<br />-1.arowtutoftt,,mrEiy.amcxclusivcly.onlEclinewiltli.cnsdonrh.lNlo$nstructllElb.iel136.?044.8usifts0nd EDf.sibn Codcr Thc C.nr0crors Liceis. Lrs d6cs ior aplly r.r !no$ncr ofpmp.rty who builds or nurov€s rhcrcotr.aid eho conlnds for such rmic.ls wirh! ConlEcbn.) licnkd l,umln o rh. Conhdois Li.c.sc trs).
<br />I nmdctr,l, uiJ.r Sc.ri,B &PC lorlhis rca$n
<br />-
<br />O*ner:--
<br />]4I}Bf,Ef,S:.IOMTENSAII!}!
<br />DECLARAI'ION
<br />I hc.cty lrrirn undcr lcnohy o! pcrJury orc ol lhc followin8 dml,rorions:
<br />-l
<br />hNc ud will nunrl.in r Ccn ific0rc of Conscnr ro S.lf ln\xn for wulkdr .ullxn\dtun, as fovidcd for by Sccrio. lTcl{l of rh.
<br />hhtr (.odc. for rh. l.rfonr&roc of rhc sorl ror wh(h rhc letr ir i\ isxcd
<br />-l
<br />hdvc 0*i sill nlinrain workcis comtc.sarn,n imur!trcc. $ rcqunc{ by SNt ion l?00 of lhc Llbor Codc. f$ lh. pc nlmrc. oa
<br />rh. so.k tur qhich rhn p.iitrir Nly s ompersliofl i.$mra catrtr and poli.y numhcr E
<br />c-I ,lu 9-'Z.otc
<br />-lccniaylh.i
<br />in'hc pcrformkc of rlE worr ror whichrhh p.nn is issned,I shxu nor cmployanytcren inlny oturcrs as k lr.om sobjr\r i. rnc wortcB oftpctrerion la*s of GliLmia, atrd a8rcc rlmr ifI \hould bccom sulrlcr ro rlr
<br />woltcn dnnp.n\ ion F)vist,ns .f Sccrtun .l7fi, ol the I iho, Codc. I ll. nrnhsilh coarnly *ilh lho\c pmvi\ions
<br />IVIRNIN(;: Fnilnrc h {c6d *orkc^ conrE.\lrinn ovcrusc nh*nrl lnd shlll subjNl !n cmplorrr lo siminri [rmllts and
<br />civil 6N! up to or. h!Blr.{ rho!{!nd dollm ($l(ilion lo lhc colr ot.onrncns.rion. danE8cs ss l]lolilcd for lhc
<br />t)t,tt.t,,\R,\I t()N
<br />I hcEby llIm lndcr p.Mlry of pcrjury lhll I am liensd uf,dcr Fovision of Chaplcr 9 (onmncing wilh S..lbn 70m) of Division l
<br />of lhc Blsiftss d Pm{csions Codc. !,i oy li:cns h h tuU lore dt .trer.
<br />c?*lo3-1-70
<br />"". \3-Loz-o ;F.-
<br />c0.Nflalcll()ril};ll)lNc,llixNct
<br />is\ucd lscc..to97. (iv c )
<br />AfI]LIIAXI.IIECITAXAIION
<br />I hctdry anim u.dcr pctr.lryofpcrjur, onc.llh. foll.sing d.cld.riona:
<br />Dcnrliliotr Pernrih'Asl*sos Norifi.olhn F.dcral R.gxbrions (Tnb 40. Pfi 6)
<br />-Rcquircn
<br />Lcltcr ol Ndirrcnri.n
<br />! ccnitrrh rhc fclcrrlrcsuhli{'ns os rcmovrlarc not rt'Ili.ahlc lo
<br />'hn I'f,rirl
<br />t-l eiify rhd I lurc rod rht arpli.ar lhrr rhc alnvc inntrm ion iscotur.l u8e kr.omrlysithlll Ciryond Counry
<br />.rdinrrtcs und Stllc,iws rcblin8 y lulhxizc rcprcsntnrivcs oflhis Cityrnd CoDnly lo cnlerupon rhc
<br />3h,F rftnliomd ropcny ror iN
<br />Applimnl or tenl SiEml
<br />I . d,fU
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Building Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarilier
<br />TOP OUT
<br />Waste & Vent
<br />Waler Piping
<br />Gas Pi ing
<br />Roof Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOL/SPA
<br />P-trap/Drain 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 />Bqugh Plumbing
<br />Final Gas Test
<br />rl
<br />)fr,(Yu LW
<br />INotesRemarksEtc.II
<br />Back Flow Device
<br />Meter Belease
<br />FINAL
<br />S.cltun 1076 of lhc Lntbr c(dc. inrcrcs,
<br />o.,", l-3-zozo
<br />Lcn'i., . Ndn'c
<br />-
<br />Ln hr\ Ad.trc$ _
<br />,,,",1'S-zazD
<br />ITBDO
<br />I
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