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PLUI]IBING INSPECTOR RECORD
<br />COMMENTStD/slG.
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under lloor
<br />Gas-Underfloor
<br />SewerBuildin
<br />Area/Storm Drain
<br />lnterce orl Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Pi I
<br />Gas Pi tn
<br />Roof Drain
<br />Tub/Shower Test
<br />Rou h Water Heater
<br />POOL/SPA
<br />rain LineP-tr
<br />Main Drain/Pool Pi n
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Gas Service
<br />Water Service
<br />rinklerLawn
<br />Sewer/CaSanita
<br />Back Flow Device
<br />h PlumbinR
<br />7/u9'-lb-,Final Gas Test
<br />Meler Release
<br />Zb-lFINAL
<br />Notes Remarks, Etc
<br />OWNER$UtI,DDR DELCARA'IIoN
<br />I lrcr.hy lllim und$ lctrrlrl I'flcUury rhi I dr cx.nrlr ti. r rhc Conrrlttr! Liccnsc tlw tor rhc lnlbwir! tcr$n (Sc']0:ll5
<br />&rcincslidl'rol$si,inCodc):AtryCiryurCotrvehjchrcquircsrPennitr)con{d'l.nhcr.inrti('}vcdcm'lhhorrcplirlny
<br />(ruc(urc,fritrloilsn\trxn.c.rlsorcqun.srltlpllionrl,trsu.h[lnnitblilcrsisnrdsldoxnrrharh'orslrisliccnedPr$un
<br />t,rtulxNi\nin\otrh.Conlntttr'sLi.cn\cdt-ns(chrnlcrg.C.mnt.rn'rwirhScclionT(xx]oiDiviri{lolrhcBusincs\and
<br />t'lo'c\\iul\Codc)orlhri ncorsh. iscxcnt,lh.rclioflrlnd lhc hJsn lff lhcJllcscdcxcn]Plnjn Atryvnlhln ofsccliod.T0]l5byany
<br />trfflicrnr hr pmnir suhjcchlhc rmlic.nl lo rcivilPctr.lrvol rxn rtrcrhrn llrc huDdt' dollars (S5(D)
<br />l. r\ owtrcr oi rhc fmNny. or my . Irbltcs wirh srSc\ N rhcn {,c .onl|Ehrri('L qill do rhc soA nd rhc (tutuE i\ 'ori*,a.r *,,n.,",1t, uit ri. ?Oi-r.8;sincls d Pr.,ts\i.ns Cdlc: Thc Conn.rois Li.cnsc tiw docs nor '!llv ro an oqncr ol
<br />tu |)opLn, v}rr btril& or inPn,vcs rltdnr, ikl {ho des \uh so* him\dlfor hcrcllor rhtuu8h his {r hcr osncmnlolccs'
<br />p",ii,rl rrti"r ",o, in{ulcmf^ m,rr i, cndcdorollarcd lntqic lll hoscvq. rhc buildins 'r irnPn)rcmnr i\ $ld *i(h r'nc Jtr
<br />;I conrlck,n. rtf, owmr Boikld *illhlvc rh.l{ cnolF)virBrhl lEor\hcdil trol huildorinDrorc thc ptuFnv fttr rhc P{x'T 'l'
<br />l. n\owrcr orrlt PrcPcnr. sntcrclu\irclycontrrira *irh li.cn*-d .onra'tn ro
<br />'on{rucr
<br />rhc pmjccl (S(' ?(!-1- Lrin'*
<br />.,,1 l',"|a..i,n C*lc, rl.l; c; ,acrois Liccnsc l.r* doc\ tror ir)flvb i.qncrorpn)p'nvwhohuildsorinr!('!c\rhctcon'
<br />dd uho .ontrr\ lnr luth pnrl.d\ wirh | &n mdonr)li.ctr{dlu^urnrt'rhcCotrltlcntrsLiccrsclja)'
<br />I rrcrctr1fl xidcr sccinnr-. B &t'( t.r'hnr'rn'n
<br />laBKEXS:lllMEllArIAN
<br />DECI,AMITON
<br />I hcreby dirrm !.dc. r.n.h, ofPojuryoncoflh.lolhwinS dml,rarioN:
<br />-thnv.otdwillminl'h0ccilrculcofconscnl|osclf.lnsUlcforq.rt.K'compcnglhn.aspmvirlcdfo.bysdtionlTm.llhcL3bor Gdc, fo. ih. pcdorn1lre of llrc *ort ror vti.h liE ll.mir is hsucd
<br />-l
<br />h{vc.nd*ill Minrtin *o cB .omPcn\arion insumncc as rcquii.d bv Scclhn l?(n of lhc L'bor Code fot fic p'rrdJm"f
<br />work for thich rhis Fmir is hiu.d My so B o'nrEn$tion iosurarcc @i'r and IDlk, num6'r @:
<br />,"\.' = rj!-re^cr.-z \)3 (to\/- I I
<br />-l
<br />artity lhar in ltE Frfor@c of th. wor* ror shich lhk pcmr k nrucn l firll mr enlllov rnv tEer h lnv l@er
<br />*. t"i,* *t'r""i.,* *rt6 smpcnslbn h*r orcrlifomi. .nd sgra lhd rf I slhutd bc{om sbj(l rc dr
<br />w*6'onlPcisiionpmvisk'nsots6lion]TOOofrhclrffCodc.lshollfolrhwilhconplywnh0E$prcvtioN,'
<br />WAININ!;: Frilurc k, {.ur. workcn .on'!.ns!l io. ot@g. is unbwtul. ,rn shdl suhFl s csyloJtr to simi.,l FEhi* dd
<br />.ivil fitrcs !t ro om hundr.d lhousnnd dollln ilion ro rh. uo{ of o'np.ns.rion. da@lcs as lrovil.d for rhc
<br />srri.n 1076 ofrhc trhor Codc. inlcrcsl !trd !!' Y't't l'
<br />LtCENSl'D (l(rNatulcT(lR
<br />DECIJXAII!]N
<br />I h.rcl,y dfirn unlcr pcnalry or Pcrjuty rhd t nm lienxn m<lci pmvnion ol Chiorc 9 (co rmrcinB *ilh sstiotr 7000) 'f Divkn'a :l
<br />ol rhc Ausincs stul Pmfcssionl codc, ard my li.cn{ is in tull lord dxl .fl&r
<br />&3
<br />I h.Eby .flro ud$ fna[y of pd.iury tn.I llEE is . otr{ruciion hnding .8!mv for $c Frfolffi of rhc qnrk ror *hich rhir Fmi is
<br />issucd (s6.lo9?. civ. c).
<br />L.drt N!ft1
<br />llnit i i AddFs:
<br />APPLICANT NFCLARATIoN
<br />I lEi'ny rflinn u tulcr rmlt, ol Frjury onc or rhc tulbwi.s dccld.rio.sl
<br />IIixn(or t'crnrir\ A\hn{s Norific.rion l:cdcral Rcgulnrirnr\ lTirlcl0. Pfi6)
<br />RL'qutcd lr cr ul Noriliclrir,'
<br />-l
<br />cc'1it, rhrl lhc fcdcdl tcBuhrions egddin8 asbcsros tmval !rc not applic,blc to rhh fojc'l
<br />-l
<br />c.nify rhlr I hav€ rcld this ion aid srol€ rhll $. atok inforfllhn is coGl. I !8re b mmplv *nh aI Cny &d Cou v
<br />ing ".n"*ii"" .ta r,"tuy -tlnirc rcIn*nidifu or lhis ciri Md counrv ro c,rcr upon tL
<br />alx,vc Enr ioncd F,rr-dy lor in
<br />Applicanl or A*enl Signal
<br />,^^rZ
<br />APPROVALS
<br />o"", F f '/
<br />-l*. f,^^&'/F
<br />DATE
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