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PLUMBING.INSPECTOR RECOBD
<br />APPROVALS DATE IDiSIG.COMMENTS OWNTJIT DT]ILI)OR DIiI,CAItA'TION
<br />I h.r.hy 3flnn uidcr Ftr.lry ()l Nrjuy rl l am cxcmni i.nr rhc (i,nrn.t$ Licctr\c lis for rh. lollowiis rcrs lsc( 10.11.5
<br />Busiric\ r Prn'c\\iotr Cdr)r lny Ciry or Counr, sh'.h rrqrnc\ r lBnir ro con{rucr. xlr.r, ,nlPtuvc. ddnxrlish or rcpd uy
<br />srrucnnc. pri(tr ro ir\ isruDtr.., trlv' rcqutrcr rhc.|fri..d turnr.i ncnir b flc r \ilicd ndcnrnr rhd h.ot \hc i\lic.l'"r,r.nu,.u3d'
<br />h rhc lrovisiqs ol rhc Coorrictr\ Lic.n\cd tjw lchxlnd 9, Connncncirt wirh Sccri.n ?(XD ol Divisiotr ] ofrhc Bu\inc\l 3trtl
<br />Pnni\\ion\ C.dc).rrhd h.or lhr i\cxcnU rh.r.liotrrMd rh.hrsi\ li,r lh.rllc8Lrl cxcnrPrir . Atyvi,,l i.nots(r(n70:ll thydny
<br />rmli.!nr inr r pennir subrc.r\rlr rflrli.!nr ti.cirilpcmlryoinor nuc rhii livc hundrcddollnrs (550(D
<br />-1.
<br />ff owrcr of thc proF(y. or f,y cn loter silh v!8cs ar thcir sle .omlctr*rion, will & 0E woll ad ltE .|nn@ i5 rcr
<br />inrcrxlcd or orcEd fo sL (Se.7o44, ausims s.d Prcfcrsions Codq TIE Conrndd'! UcnE Lle &E5 nol .pply b s owrcr of
<br />rlE nmrEny wln ttuild.s o. inmB dm( rd who dc uh wlt tntrelt 6, hcBltor fimu8h hn c h.r oe, coploy@3.
<br />pmtidodrhat such imImEm.B e ftr hr.nd.d o.ofr.rd lor sL. lf. hoq*r, r,E t{ildin8 or itprowm hsUsithinoncFe
<br />ofonphion. ttE Oxmr Builbr will l8r rt* hldo ol nNvang thlr lE or shc dtl ml tdild or irpDw lhc pmp.rly for tlE ,urF$ of
<br />l.soBrcrofth.IrcFny,amcx.l!.ivcly.ontocri.Swnb.cn*dcofllraclo6loonrru.irtE,,.jet(Scc.?044,Busiocs
<br />snd EDissi{ Codc: Th. Co.ra.bas Liccn$ Law d@r.ot aDDly lo Mowner ofrrcp.nyqho build. o. imPrcws thcmr.
<br />rnd who onuacrs ror such nmrns wirh . Cona&ro(r, tk.nsd pu6unl lo r C6nIeloas Lh.nF tiv).
<br />I n'n.xcnfl undcr Sect
<br />wonxFILs' (:(tMPE-llSaTloN
<br />DECLAf,ATIJN
<br />I hcrcby ani utrdcr p.mltyolpsjuryoe olrhc followins ddlmrionsl
<br />Iha\crilwlllnrntrxtur(tnifEarcolCtrr.rhScllltr\urcnn$.rkcrr..nl.cn$ti,)n.r\PmlidcdfotbyS.!rii,n3?(x)olihc
<br />l:$.rCixlc- r rhcpcrronmn..lrhclork tu rhichrhc t^-nnil i\ i\{tJ
<br />Ir have ond will minrrin porken conpcnsarion inslram., a. Erluircd by Salion l7m of lh. tib.r Codc, for llE I'dforuncc ol
<br />work ror which lht lcmir G Lr$.d. My so*6 6tp.nsio. insut!tre csi. dnd Flicy .umb.t 8:
<br />9\ frre, ,.D14 ltrr,)<r+Yrrr^s {^9S FUpD
<br />a5(2 .t@ t8
<br />\ r.ni,yrhd i'r rlr jrrlonnrn.colrhc sort n $hi.hrhi\pcnni( i\ n\x.d.l rhrll nor cmpl'y !r, I[rn irrrtrynrrncr
<br />v' r( t,li{urr rhl.d b rhc *o.li.^ .onrp.tr{rnrn hw\ olCrlitunnr. rM n8cc r[rr itl sln,u]d hc..m n$iccr io rtf,
<br />wulkcF.onrnn\rrhnpmvhionsofSccrio..lT(DofrhrlrhtrGdc.lrlull.bnh*irhcomlly\ithrlFsnlori\i.n\
<br />WARNNCT Failui. ro scm wo c,s conpcnsrion orvcagc ir unltwtul. d shall sub,.{l & criployft ro aininal pcNht. and
<br />ciril nrd u,r ro oe hundrcd lholsnd dollad ($100(x})1. in ddirion ro lhc co( of coml,ctrqrion dadgcs as P.ovidcd lbr ih.Y:lniru-^"^ifl*aaffi
<br />Df.CI,ASAI'AN
<br />Ihcrcnylirtmundc,Fnahyor,r.rjuryrhdIomlicuscduncrpmvi\n,norch,prcr9(.ommncingrirhSccrionTuxr)ofDivision3
<br />of lhc 8usircs a.d Pofcssi.n\ Codc, ,rld ny lkc.\c h in tull rorcc ud carccr
<br />qafe
<br />IOISIBIJIIIONITNIIN!-ACENCI
<br />I hrNhy finnrudcrNnrhyol'pcrturyihrrrhcrcnrc.i{tu.rionl.nlli.8r8ctrcyli)rrhcp!rlornutudofrhcwolkitr*hichrh'\Frnliri\
<br />istrcd rscc 1007 Civ C ,
<br />a.ulll.;AN:Ll)lrcldSau()N
<br />I hotl, aJlm nndcr Fnaxy of pcrjury om of thc tolk,wins dccla,r' ions
<br />Dcmliiion Pcrmih A\bcnos Norifi.0ron Fcdcml Rceuldiotrs Oillc40. Pana,
<br />-Rcrtuircd
<br />Lctrcr ol Noriarfl rion
<br />l..nrryrhar thc li{!r.l lc8ulnthns ssadin8 rh.no\ E,tulrlrm nor apfli(nble ro lhis proFr
<br />I c.dilylhd I halc rca'i rhis 0pplicrriotr zrd ndr. rha h. d.vc inlnamtion h cotrcd l,sre$oftFly*nhdllCnyandCornry
<br />odinamcs ard Sllrc tnws Elaring 16 building c.niru.rirtr aid h.eby.ulh.ri. rpdemllives ofrhis Cny 8nd Cohtylodrcr ufl,nrh
<br />)\ AJ\&T a/1 A,lo <:t ,tt 4\)
<br />UNDER GROUND
<br />Water-Under lloor
<br />Gas-Underfloor
<br />Buildino Sewer
<br />Area/Storm Drain
<br />I nterceptor/ Clarif ier
<br />TOP OUT
<br />Wasle & Vent
<br />Water Pipinq
<br />Gas Piping
<br />Roof Drain
<br />Tub/Shower Test
<br />Rouoh Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Main Drain/Pool Pipinq
<br />Fill Line/Back Flow
<br />Pool HeateriGas Line
<br />Miscellaneous
<br />Gas Service
<br />Water Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />Rouqh Plumbin q P",r(t>ltolrg qo gt '.4*/fit)
<br />Final Gas Test
<br />Meter Release
<br />FINAL /t+/rq st\trx
<br />Notes, Remarks, Etc.
<br />+
<br />trn'lrr'. N nr
<br />-
<br />Dtx,tc tu rioNd tmNnyror insFclionplr,x)e\*, . n /sla:
<br />Waste & Vent
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