|
APPROVALS DATE ID/SIG.COMMENTS OWNEi BUII,DEN DF:I,CARATION
<br />I hcrcby aflinn Dnd$ lcn{lry {)f p.4uiy rlrar I en cxcmrrr fro'n rh. (in{rr.rrr l-i.cnsc ljw for rhc followirS rc.$n (S(r0:11.5
<br />Busnrcss {d Prolcsrnrn Co{c) Any Cny or C.unr! uhi.h r.qurc( i r^_rn n, con(ru.l. rhLy. improlc. dcmolish ot rcprn ony
<br />drucrlrc. I'inro ns nsuan.c- alv, rcqunc\rhc lpnlicanr lbr cn pcllit ro flc ! si8rcd nlrc'ftnr rhlr hco, shc i\ li.cn{d ttr!tuanr
<br />ro rhc l]I)visnn$ ol rh. Cotrtlcror's Lic.nscd ti$ (Ch.ptcr 9, G,nncfti,r8 f,ilh Scclion Ttroo ol Divisiotr ] ol lhr Busincs\ atul
<br />Pofcrrion\Codc)orthrl hcor shc iscrcnu rhcrclionr.Nl thc6isis ror rhc.llcscd cxcnrprbn Any vi{nrrn,n ofSLrrt,nTOl,5 h, rtry
<br />nftli.ur ntra pc,ntir luhjcrrs rlr !mlicror lo r.ivilpcn!lrrof.ot D,orc rha fi!rhuidrcdd.llnr\($5fi))
<br />-1.
<br />ds owmr of lh. I,trIcny. or ny .mololBs wi$ slgcs trs lhcn $k sq,cnslion. will &, rh. *o* !r'd rlt srnEr@ L rcr
<br />itucid.{ dr oreod for sle lS6.7tX4, Burim* and Profcssio.s Codd th. Conrtutr s Licnlc L.* docs ml lDply ro d oqm or
<br />ih. pmFny wl[ blilds or iqms $cs)r snd who dce srch eit hnnclt n lrrelf o, thm!8h his or n r own cBl,loyes.
<br />prolided ihlr su.h inlmhmnts m ml intc,'d.d nofr.nd lor $L. !l howw. E building or impmrcm is sld wnhinom rq
<br />oaompkrion. rlE Owr BuiHcr will hlr rtr l lttn of prcvin8 rrd t* or shc dn d t0ild or irym* lhc,,otsry for UE,oqNof
<br />_1, B osnc.oarlE lopcnr. oncx.lusivclyco.lr&ring with lienrd co raclouto mnntud tlE Drci (S*.7044. Buiires
<br />ad FDftsshn Codc: Th. ConrdcroCr Liccnsc Las d6 mt apply ro d o{ffi of propcrly who builds or inprev* $crn,
<br />..d *lD co e's to, skh po.ie.is wirh ! C!tnEcro(.) lien*d,E@r lo ri. Contrelols LirB li*).
<br />lrtrrcxrnrnr un,l.rsc.ri{nr .ll & l'( lnr r['\ rcryrr
<br />IOBEESS:COMIBTAIIO!
<br />DECI.A8AI]qN
<br />I h@by amrn lndr peMlry olpedu.y orc ofthc follovins <L.knrhB:
<br />l]txrC,xh. ntrrh. ptrturn n..of rtu work larqhi.hrhctdnnii i\ i$u.d
<br />Ihavc.trdwillmdinrrinworkcrlcomrcn\.rioninsurnrcc.0r r.quircn h, Scclion ll0o oflhc L.bor Codc- for rhc Frfortu cor
<br />rhc work ior uhkh rhislr nil i\ rssu.d. Myworkcis compcns.t,on,rurarcc clnicr nn policynlmt ruc:
<br />c.,,," 3-?A1e Fu^.rD
<br />I 8 1 111 o 1- (- 24t\
<br />-lccnifyttut
<br />inrhcpc ormrct olllE *ork for *hichltir pcrm as iisucd,I shlll nor.nploy a.y p.son inlnynBNr
<br />$ as ro tlmm subj.d ro lh. wort N'comp.nrdion lnws ofc0liLmifl. rnd a8N lhlt if , snould b.{om slbj*l lo IIE
<br />wor*6.ompc.salionrmvisioNofsdion3T(x)ofthclnttrC.dc,lslull.fonhwithemplywnntDspbvisionr
<br />WARNINC: Failurc ro sud erker oqM$lion owEgc is lnla*tuI. lid shrll 3lbjNl 6 cmploy.. ro aini.,l p.Mnics.,i
<br />civil 6fl.s up ro om huidrcd rholslnd doud ($100.000). in .ddirion ro rhc oir oI onUe.$ion. dlMgc5 rs pDvaod for rhc
<br />Sdrion 1076 of rhc Lator C.dc. inkBr ad anoftr\ ts.
<br />D.,", E -(' lt
<br />"+tf,
<br />e<-
<br />UIDNIEDI:ONIIICIAA
<br />DECIAAAIA!
<br />I h.rhy a16fl, und( lcn yorpcrjuryrhar I m li(n\rd undcr povi\ion of Chi/d I (co'nnrncrn8 wirh Sdiotr 7m0) ot Division :l
<br />ol rhc Busircs.nd Pmtcssions Codc. a.d my licenic n iD tull lore nid cltccr
<br />B 1t1872-
<br />COdiIBIJEIIONIENI)IIC.ACINII
<br />I h.rchy rlnn un(lc! nlnihyolpcrjlryrhrrrhcrri\r coi{n'cri'. lctrdir! trgcic! f(trrh.t nnrm.cofrhcqor*forwhi.hrhtNrnritn
<br />i({rcd (Sc. 1097. Cn C )
<br />AIILICANLDE(JdAAUAN
<br />I hcEny aijm uodcr ll.nllly olIlc jury onc of rhc folhwnrE dccLr.rions
<br />Ocrtulirion P.nnns A$.i.s Nori,l..rion f'cdcDl RcBUhtn,ns (Tt1.40, Pd6)
<br />Rrquircil tdr$of Ndifi .dion
<br />-lccnilyrhrr
<br />rhelcdcnlrcgulorions Elnling!\hrsro\ rcnn,vrlarc no! uIplic,l,lc iorhii poi.r
<br />Qfr..n,1,r,, rr'"'",.,1,r'* lldtr. r,n dd ! r c rhr rhc 0h.vc nrroflrxtrion is corcct. l .Ec ro omply sith ull ciry !m, coonr,
<br />odinrn.c{.nd Sr,rc l-aws ftbrine ro hnildin8 construdion. und hcBb, nurhorizc rcprcsnt.rn$ oilhh Cnyond Couiry ro cnrcr ulx)n hc
<br />rboec nEnrionci Imllcny lor in\IE rion purFxcc
<br />e-L-Appuent or AB.nl SIBn.lle- . -hr I
<br />r)
<br />UNDER GROUND
<br />Water-Under floor
<br />Gas-Underfloor
<br />Buildinq Sewer
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Pipino
<br />Gas Piping
<br />Rool Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />lvlain Drain/Pool Pipinq
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Gas Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />Rough Plumbing
<br />Final Gas Test
<br />Meter Release
<br />FINAL , lslty .^/n?@Notes, Remarks, Etc I
<br />PLUMBING.INSPECTOR RECORD
<br />o",., 6-l-tx c-,^.. F#r.F 22,
<br />Waste & Vent
<br />Area/Storm Drain
<br />Water Service
|