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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OlVNlrL BirlI-DUR lll.ll,( ARA'l I()N
<br />I hcruiy rfllr uidrr |{trtlry .f pcrjury ihrr I m crcnru lilrn rh. Cotrrr.rrs Li(c.\c tjw lur rhc knhwir8rcr\u (Sc.70.11.5
<br />Busnrcs rnd Pdcssidr Codc) Atry Clty or Cor iv shich rcqunc\ r rnir r. con(n'.r. ollcr, inll,.v., dc'mli\h or rtr.! My
<br />nrucrrrr. priqlo ir! n\uircc. oh. rcipncsrhc rtpl(rtrr ntr \u.h ltnnirh lilc a \iE cd nncnf, r rhrr h.or \hc ii li.cnrd pnr\onnr
<br />h lh! tro$sotr\ ol r,a Co rd.ttr s Li.rn\cd Lf,s (Chrlrcr o. a'nnn.nuins $nh sc.rio 7lx)O oI l)ivi\ion.1 ollhc t,u\irrsr rnd
<br />Pnrc\\i,,,sCod.rorrhar tf, or \h. t cxcn,rl rhcr.lronr d rh. blis for rhr rlLlcd ctc rt!o Antdnrrinofs..ti,n701l56tLn,
<br />{llicrfr hrrpcnnn suhjLrrsrhc rfplicrnr h rrlvilncNlryo, nor mmnun rivc hu rddollnre(S5rD)
<br />-1,
<br />a o*B of rhc popcny. m d.tu\iEly conlrurins *nn lia.kn conrn roN ro.onsrud rn l,mtrr (Se. ?tra4. Busrffis
<br />und PtoEsion Codc: Th. Conlmiols Li.cns. Lnw des not amly ro an owner ofl.oF,ty who buitds o, inp.ows rhc,@n.and who .oni6cri lor s.h liqers eirh a Co acro(s) liensd puilusnr to lh. Co racrols LiccN l,*).
<br />-,
<br />rmcxcmpt und$ Ser B & PC lor'hi\ rclson
<br />()*nEr:
<br />uoBtr![5]rauLDltalloN
<br />UirLil.BAUIrN
<br />I hcrchy nmnn undcr pdmlryoiprrjrrt orc orrhe foln,wins dcc,rdions:
<br />lhtrv.Lndwilltui.'lir!CcnificlrcofConsnrroSclllnsurcforwork(l$q,cnsrlion.osprovidcdforhySNrionlluoolrhc
<br />L or Cdu. nr lhc p.rrorroncc olth. *olk lor which thc p.rmn is issucd
<br />-l
<br />harc rnd eill mainlaii wolkeF .ohpcnsalion insuEnc.. N EquiFd by Scclion 3?00 of llr lnbo. Cod.. fo, dE Fnolll@c of
<br />lh. worl fo! which rhn p.mn is h$cd. My sortcB coqxnslio. insuftncc caEhr and lDlicy numbcr ml'Tra^vclcrs
<br />u65J 8l-l 5)q l-lJ6G Q JE15
<br />-l
<br />ccnify lhar in rh. !.rlnrmncc olrh. work ror ahkh rhis r.rmir is nsu€d.l ihlll not cmploy sny pcr$n in uny ftanrcrs !s to l8om sll,rcl lo lhc *orktrl comp.nsalion hws ofcaliromi( rId rgN ihar ifl rbuld b.{om rubjccl ro r
<br />uortdi onpen\llion pmvisions of Sdiotr 1700 of rlE Lnbr C6dc. I shall. ronhwiri conPly virh rtos ptuvisio.s..
<br />WARNINCT Failure to surc wortcr coDpcnslrion m$ft8. is uhhwlul, ond shall subicr an cntloycr lo riminal Ftul'as &d
<br />civil frncs W lo onc hlndrcd thourand doues ($loo.Om). in addition lo thc cosl ofco,Vrcnscrion. d.m84 0s providcd for fic
<br />Sediin 3076 of rhc kbo! Code, inlcrcsr and altorrcy s fes U/"eN-", ' Q -(E
<br />LI(]FNSF:D (I)NTRA(]ToN
<br />0&qldn6.r&!
<br />I hcrhy lnnnr ufld.r !.nohy ol pcrjury thul I rn li.c'r{d undcr poeitior orchafl.r I (connrncins eirh Sccrioi TIXD) orDivnion l
<br />of thc Blsimss .nd Profursions C.dc, ,rrl nry lkcn{ n in flll fitre ud rllirr
<br />83 tg L,I. 6-C
<br />o.r., 1 Q -ta<6
<br />taliuuglltNrENollc-acENct
<br />I h.(by rflirm uodcr l](nrllrofpcrJury thlt lherc is acotrsrucrio. bndn,g 08ctuy for rh. pcLmurc ofrh. worL lor which rhis Frmt is
<br />hsucd (S(. 1097.Ci!.C ).
<br />AITLICANLDECIJSAIIOA
<br />I h.r.6y,hlm und.. trnalty olp.lnry otrc ol'hc fdllowin8 dcclmrn,ns:
<br />Dcturirion Pcrnirs Asbstos Norificarion irdcmlRc8ulotions (Iirlc '10. Prn6)
<br />R.quircd t-n.r of Ndifreri.n
<br />g"-.
<br />"*11."*".
<br />nit th3t lnc icdcral rc8ulal ions EgradinB {sbcsros r.m!d @ nor !|)plic.bL ro lhk troj.d
<br />) rh.r I htrv. rcd rhis ,mli.arion nnd narc rhd lhcltrvc inlormalbn ncomd I asE ro&mplrwithallCirrrnd Cou.ry
<br />md S'dc tjws rl,ring lo bx n. ud hcrcby aullnrizc rcprcsenrulilcs oflhh Ciry und Counlylo cnlcr ua)nltE
<br />ahoe mmk,red phl€fly aor insl€dtun
<br />Apllicdl or ASdl SkMtlc: )<.
<br />d
<br />,.,.'g-16-lE
<br />UNDER GROUND
<br />Waste & Vent
<br />Buildi ng Sewer
<br />AreaiStorm Drain
<br />lnterceptor/ Clarif ier
<br />TOP OUT I
<br />Waste & Vent tulnm ,fVt@-d?,b)
<br />Water Pipino I',t I u l'<--
<br />Gas Piping
<br />Roof Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOL/SPA
<br />P-tra p/Drain Line
<br />Main Drain/Pool Pipinq
<br />Pool HeateriGas Line
<br />Miscellaneous
<br />Gas Service
<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 P Ld Kfi r^r"err)72)
<br />-
<br />I at v
<br />-L
<br />Water-Under Iloor
<br />Gas-Underlloor
<br />Fill Line/Back Flow
<br />Notes, Remarks, Etc.
<br />-1.
<br />us 6wrcr of lh.ImIEny. or my cmployes wnn w$cs ar lh.n $b 6np.n{ion. willd. rlE wqll aid llr s!,lxfu k mr
<br />inLuLd or orcrcd for eL (Se.7OI.l. Buriftrs and Pnf.ssions Codo: Tl. ConrE rm s LicmE Llv .lod nor .pply ro !n owBr of
<br />ItE poFny *lE ttuildi or nqmEs th.m( !,n wno &ca sh wi hirell o. tE^cl[.r lnrcueh his o. h., oeo crployes,
<br />Drolidc<! ln4 $cn inprowmnls m ml i cflLd doff.cd 6r sh. r. noME. lhe hiuhg or inFBrBtrt i! bB *nhi, om ju,
<br />olconphtion. tlE Owrer Buiud wiu h.e dE bu&n of lmvin8 lhlI lE or shc di, tur buitd or ihprcvc $c l,Dpcny for th. lD,Ibs of
<br />L.ndcis Addrss
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