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APPROVALS DATE ID/SIG.COMMENTS OWNER AUIDEI' DELCARA'T!ON
<br />I hcrchy trlftn nndcr lcnrlry ol p.rjury rhar t a,n crcnl,r lin.r rhc Conrcror' l,iccn* liw fr rh. tollowinS ravr (S.c 70ll 5
<br />!]ustrc$ rtrJ Prcfc$nnr Cqtc|
<br />^tr,
<br />Cily or Cou"ry {hth rcluirc\ r pcnnir k, L\,nd .r. ahd. iqnovc. dcnnlish or El)air lny
<br />ntudo.c. prt, ro ns issuan.., J\' tuquircs rh. rptlkad nrskh Frnir !, ilcr\i8ncd n$.,rcnt rhrrhcorshc i\ licc scd , r$xnr
<br />lo rh. prcvnion\ ollhc Connn l{n \ Li.cn{d li* (ChJptcr 9. Commcmin8 liri s..rn,n 7fix) or Divistun :l oi rhc Busirrcs\ nnd
<br />Pri,L$nnr\ Codc ) or rhar hrorrhc iscr.Npr rho.li.nsnd rfic hasi\ f(n rhc,llcg.d crcmlrion A.t vnnlrionolSccrionT0-ll5 hyony
<br />.ptlm lor i Nflnn sublNh rnc lpplic0nt io rcivilt.nolryorDormrc'hrn fivc hhdrcd dolhr (S5(xr)
<br />I1lr. ^ ." rc. "r rr'" r,-r"ny. ,tr
<br />'ny
<br />cnln[,y.r\ $ hutra.\r\rhctvn..o,np.nsdn,n.qilldorl'.w k (d rhc slnrrm i\ rtn
<br />inrcrxldl .r oltrcd for slc (sa 7()t,1. Busircs and Pnrlcsnnl Cqlc: l ht cl)nr8.i{n \ Licci* tls des nor mrly ro r. o+ er ol
<br />rhcm)Fn, sh. htrilds or nnpmrcs rhcBnr. oxl wlx, d.cs nr.h w.* hiDrll or hcr*lf.r rhtuugh his orh$own cmpl.yccs-
<br />prorid.d rhar sr.h impmErunh m mr inrcdLd or otlrr{ f{tr slc ll h,mkr, rrt huidn'8 ff nrrn\tm.t is htl uhhin n't ,tr
<br />ot.onfkrion, d. osr*r Bu dLJ *illhNr thc budctr ol[ovin! lld hc or shc ai.i nor huild or impmyu thc rtutdy ror rh pu{n{ of
<br />-1,
<br />as ownci ofrlrc pmpcdy, m .xclnsivcly .onr.{dine wnh liccn$d c.Nm.ror ro €nnrud $c rmi{l (Sec. ?0+4. Bu\in61
<br />old PDresbn Codc: Thc ConrEctols Liccnsc Lsw docs nor q,plyro an ownc, otpoFny who builds o. in hwslhcron,
<br />and sho onrEcls for su.h tbjccls sirh a Co 6cto(i) liccnsed Duisufl ro rhc Conlraclols Liccnsc L3*).
<br />I lmcxcmDl undcr Selion . B. & P
<br />'",. {llt l2o li **}(
<br />DECIdBAIIIN
<br />I lErcby alltrn undcr perulty of rqjury orc ol llE follovin3 dcclual ions:
<br />-l
<br />hrvc rfrlrillnrirrrin 0(tniicrrcol'Conscnr ro Scllln$trc li,r sorkcr' d,mpcn\nn,n, 11 pn,vidcd tu6ySccrn :l'l(x)ollhc
<br />Iihtr Cdlr. itrrhcFrfomrn col rlf qo.t lirahichrhc pcflnir it i$ucd.
<br />_l hrv.lndwill minrsin sorkcr' .omp.ns ion insu6ec, as cquiEd b, Sd' ion l?00 or lnc ltbor Codc. fo. th. pcdomN ot
<br />rhc work for vhi.h rhG ll.mn is i{ued. My eork s' con{xnialion i.sumk cMicr ard polty nu'nbcr acl
<br />PolEyNumt r:JrDirs
<br />1(, ,*rr,n.u .,n" r.",*nrc nrrhc r.,l Inr lh'ch rhk pci,nir is i{uci. I \hril nor. ,rloy rny Nnon ir rtry nunrcrt.h^r.hionr.ulrdnincqc'kc'.,.i't,.rr0rn{r,,w..'.rl'1{.na.rrdx0rc"rhlrrl'hourdhcc.m.uhi..,L,,rf,
<br />sortcn .onrll.n{ i,)n pmli\bis of Sc.r n,n l7m ot rh. lihtr Gilc, I shnll. fonhwirh conDly tr ilh rho{ polirionr
<br />WARNING: FailuN lo $curc workcrs mmpcnslion mlcmec is lnlaqtul. ond shalt elbrel !n cnplorr io sinnnal ,cMllia and
<br />.ivil ,irc. up ro orc h!.rtred tbousand dolbr {$loo,flxr). in addilion lo thc cost of coqt.srio., damecs at provncn for lhc
<br />S6ri6n :1076 olihc kbo. C.dc inl.Esl*.€lls lwrl - lppuotr-K
<br />DECI.Af,AIIAN
<br />I hcrcb] ofiirn uadcr Fn0hyolFrjurylnd I an liccnsd lndcr t'oltion orChanrd 9 (con$EncinB wnh Scdion 7000) otDivision:l
<br />oi thc augiNss and Pottssi,ns Codc, 0.d my li.cns is in 6rll rbre rn cfial.
<br />Corhrtor:-- --
<br />CONSIf,UCEOIITENDBOIGENCI
<br />I i@by lllrm und6 Fnari, ol Fdury th{ llEE t a odnu.lion lndi,8 rSmy for tlE Ffortum. of llE s!* fo. which tl s Fmn b
<br />isslcd (se. 3097. civ, c,).
<br />AIPIIIAILDECIdAAIPN
<br />I hstby a,tim udcr p€nahy of pdiur, om ol lhc lollowi.e d(ld.r io.i:
<br />Dcmolition P.rnits.Ash.stos Nolificarion !-e&Bl Rcsubtions Onb 40. Pd6)
<br />-Rcquircd
<br />Lcrrcr oa Nodforbn
<br />P(m rc.!nr(print) X\-
<br />UNDER GROUND
<br />Waste & Vent 7-ao-\tr N.l#Ia)
<br />Water-Under floor v \-/
<br />Gas-Underfloor
<br />Buildinq Sewer
<br />Area,/Storm Drain
<br />lnterceptor/ Clarif ier
<br />Waste & Vent
<br />Water Pipinq
<br />Gas Piping
<br />Roof Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Itlain Drain/Pool Pipinq
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Gas Service
<br />Waler Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Rough Plumbing tplrslr<T ih^rlJ i'r)
<br />Final Gas Test ll \l\
<br />Meter Release
<br />-)FINAL I45ltT1 7/.fV\61 /4y'u)Notes, Remarks, Etc.
<br />PLUMBING.INSPECTOR RECORD
<br />&d Counly lo cntcr utDn Lhc
<br />ahove ftntiomn prcpcny lor hspcdioo
<br />&r+P
<br />TOP OUT
<br />Back Flow Device
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