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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I h...by.lIro utdr p.mhy ofFoury th,l I D.x.mpi tDm llE co riclon Lic.M Llw for $c loltosing dsn (s€.?011.5
<br />8uiin6. a.d PmfdsioD Co&): Any Cny or Cohly tr'iicn Rqlnd ! p.nn ro @ 5rucr, ah6. itrrpElr d.mlith .r FI{n 0.y
<br />itNct'tr., prhr ro ils iiiw@. ats r.qui6 1hc apllts| for sch ,.mn lo fl. . tiSEd !lal.m.t th.l tE or 3h. ir li.car.d oll@nr
<br />ro rh. povi.ios of i. Codncrd! Lien*d Llw (Chlrlr 9, Conlmring Fnh S.crion 7000 of Divirion I of lh. Buiin.B lrd
<br />Prcf.sioN Cod.) o.thar tEor E i! q.mrt ft.cfibnsid 0. bsis fo! thc !lL8.d q.mplion Anyviolalionofsc.rb. T0ll.5 by.ny
<br />arplica for a p.mit objes ih. .prlicrnl ro r civil t mliy of ml mE lhs fiv. hlndr.d &llM (1500).
<br />-1,
<br />ar olm. of lh. Im!.n, or my rmploye ,ilh wass as llEn $1. sqi.Mrio.. wil .b lh. vor* drd tl* drud@ n mr
<br />inrarH or o,Icrcd for sL (S(.704d Bu.irss dd Pmf.sio6 C.d.: 1'h. (tnlEclor'r Lic.trk L., &rd Nl qi!!y ro dn owrr of
<br />th. ptu '.ny sh. h <r! .r inp,lE tlEmtr rid wlD d.6 sch wd( hims.lf 6r h.elf6r thmugh hh or h.r own .nploy.6,
<br />[ovid.d rhar soch iDpmrd.lts e ml nnc.d.d or o,nr.d fi)r sk tf, lrw*r, dE huildinS or ir{mEmnl k $ld wnhin oE Fe
<br />of6q,Lliotl, rh€ Ow*r Buildd will haw th. tu&. ofrmvfu $al tE o. ih. did d hoild or in'pmE lh. ,,mpdy for llE I,uqB* of
<br />l. as owr ofrhc pmn.ny. !h .xcturiv.ly.o.hcr ing wnh licosd conlEcloB to sn{rud rh. lojer (Se. 7044, Buims
<br />and PEtrnn C6d.: Ih. Conl6cloa s Lic.nF t.w do€s mt .nDly ro rn own.r o lnnp.ny wh. huildr or imDmvcs lhetsn.
<br />and whn onr@rs fo, $ch plbirrr wiih . co.rEcr.(r) |i..tr$d puls.r ro lh. Conl.lcloi! Lico,. be)
<br />-l
<br />m .x.mrt u.dcr Secr 11 &PC for rhE roq,n
<br />WOTTKE&SI COM Pf, NSATION
<br />DECIdEAIIA!
<br />I h.Fby 6ltm und.r p.dhy olrdjury o& ofrh. followilg d6horio6:
<br />I h0rc ond w nl minr.in . C(nr nclre or Cons.nr t' scl,ln rc l.r \ o, ksl 6n,pcnsrnrn, as plrvd.d firhysdhn l7r)0 otthe
<br />L.hr c(de. nr rh. n$lomnc. of th. work nr which rhc nanrn h Fsur{l
<br />-l
<br />h!!c 6nd will hlinrain work.E omp..iati.n immm.. 6i rcquiEd hy Set ion 3700 .f rhc t to. co&, for lh. pnftmamc 6l
<br />rh. wo,k lor which fih p.mil i! is.d. My worl(m comp.nsrnJn insmmc ediftr'd t$hcy nunb.r a.:
<br />-l
<br />c.nify (h.l in rh. !.laormru. oflhc work for Ehichliis p.rmn ir Lrs.d.l slhll Dl .mploy.ry p..sn i. any manM
<br />m s to l,.com $hjd to thc m,t 6 @npaeloh la*! o a c,liaomi., tnd 0sr thar if I rh.uld $..om flbFl to llE
<br />wo*6.omr.nsriontmli.ioBofserion1700oath.btorC.d..IitEll,fonh*ilh@q)lywnhrlrstmvisions
<br />WA(Nlllc: ldiluE lo *te qdl6 @mpdution 66.!E ir ulawtuL di sl$ll ebjdt m dnrlo)r. ro dioiMlFehie lid
<br />civil lin . up to oB hundr.d rtEusdnd dollan (1100.000). in.ddnion ro tlE coc ot@ry.Mlioq dmle.i $ pmvid.d for rlE
<br />S.clion 10?6 ofrlE lrb.r Codc irr.En 5r'd alronEy! fd.
<br />ApDuotrr'-
<br />uclalD)-coNraAcroa
<br />DICIASAIIAI
<br />IherehynllrnrunderFnrhyolp.rjuryth,rIamI'c.f,s.{undrpn'hio.ofchnplerq(conrmencnBwrhs.crnn7l)001oiDirk'on.l
<br />ol rhc Buen6, Md Po,ssions Code. !ry1 nry ncen{ R in tu|l ri,t. i cfiecr
<br />coauxlEr&uIluDlNc-ecfNcr
<br />I hcEhy nmrm undcr Frolry olr,.rlu'-a thll llEE s a con(Edbn lcndins ls.tuy hr rh. ,.rhmrrct ol lh. sork Inr *h,th rhic ,.mn ir
<br />issucd(Scc ll)97,C1v C.)
<br />AftllcArLltEclAsauQ!
<br />I h,y.fiimunder D.ntrhyoIp.rjor-worcof rlE lbllowinr d.cl.dions:
<br />Dcmlili.n Peinrs-a.lEsto. Norific ion l:.dcEl R.3ul.lions ('l'irl.40, Prd6)
<br />RetuiEd L.tr.r olMtiliqrio.
<br />-l
<br />c.ni8 lh.t th. fcddll rsulandN Egardin8 olh{rG r.mwl .rc fl arpliobL rc rhiq t mjer
<br />-l
<br />ccniry thd I lsv. dd rnis lrrticorion ..d ,arc rhlr rh. ob6rc i.lo@lkrn is corut. I .sre (o mmlly wnh o[ Cily tnd Cooly
<br />ordi@n6 !d Stn. L,ws Ehtiis lo ttuildins codtuclioi. &rd h.rcbyNlt riz. r.rrcnldiB oflhh Cny..d Counlylo.nl.r qDn lh.
<br />dborc ffirion.d php.ny f6r iBFdion DUrp(Er.
<br />,\ppllcorl or &eol slgnituft:
<br />UNDER GROUND
<br />Water-Under floor
<br />Gas-Underfloor
<br />Buildinq Sewer
<br />Area/Storm Drain
<br />I nterceptor/ Clarifier
<br />TOP OUT
<br />Waste & Vent
<br />Water Pipinq
<br />Gas Piping
<br />Roof Drain
<br />Tub/Shower Test
<br />Rouqh Water Heater
<br />POOL/SPA
<br />P{rap/Drain Line
<br />Main Drain/Pool Piping
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Water Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />Rough Plumbing
<br />Final Gas Test
<br />Meter Release
<br />FINAL lUtpl,t qt\Kt
<br />Notes, Remarks, Etc.
<br />Polic, Nldb.r:-ExlJiB:
<br />-
<br />L.odeis N!m.
<br />-
<br />Waste & Vent
<br />Gas Service
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