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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNTN BUILDER DT.)-CAI'ATION
<br />I hcrchy atfinn undcr pcnrlr! oi rcrjl'ry rhar In crcnfl im lhcConrrucktr\l-icctr\.l.!Nlbrrh.loll'wintEr{,'lsN70.115
<br />Burin.* n' Prurc\snn C.dc): AnyCnyor Counry qhich rcqlncr rl(nri b.o nfld, ulr.r. nnrn,vc. d.nnhh or rclnn rtry
<br />s,mrurc. priorro irs issnMcc. dl$ lcqun.snr aprli.rnr fd \u.h,f,i,nir rr nh. si8md s.rcrmnt rhd hcor shc i\ liccnrcn puNuutrr
<br />t, ihc pn,v(ions 6f lnc Contrr.ttr \ Li.cnscd tnw (Ch3lrs 9, C.mnrncing snh Sc.rion 7flr) of Dilki.n ] .f rltr Busin.rs 0nd
<br />t\onssionsCodc) orrhtrrhcorshc iscrcnrfr thlrcfionrnd rhc bdris hr rhcnllc8cdcxcm i.n. AnyviolrliorriSccrirT0.!l5t\y0ny
<br />rpplirrnr fin a pennil s!hjccr\rhc rppliclnl ro!civilr.ntrllyo, nol morclh.n nr. hundrcd{!ollDr\ (55(X))
<br />&., n*u", nt rl'" p,oll.rrl. or trrycn[lo)r.\ wilh sdEc\ rs rhctr *rc.onl|]ctrsrxotr. wrlldo lhc trork rtrd lhc slMrurc i{ rn
<br />inrcndcd or olTcrcd for {lc (S( 7Or-{. ,tusi.c!( rnd Profc$ions Cdc: l hc Conlacrn \ l,iccn$ li* d.c\ nor lpply kr ai ownr ot
<br />rhc Dbpcny who boilds or imptuvcs rh($n. Md qlh d(d \uch mlk hnn{lfor hcncllor rhnnrth hi\.r hcr o{n cflr,,loycu\.
<br />pft,vidcd rhrr such iatp(Mm.rs!r. ninrcdddorofl'cddlnr{tu.lllx,{c!cr.rhchuildirSorirpn,crnrnr($ld$irhin,{r,l
<br />.lcoq,htion. ltE Owncr lluildcr *ill han dc hunlcn olFovins rhlt hc or shc did n,l lxikl or imlmvc rhc pnrlcny itr rht purF,rur
<br />-1.
<br />as owmr of lhc l,Er.ny. M crclBiEly .onlm.li.8 wirh li.cn$d conlrfttor lo sNrdcl llE poid (Scc. 7044, 8u\iruss
<br />ond hDftrsih Codc: The Conlrcror\ Lic€n* Lrw d@s ml lpply to an owncr of |rop.n, sho builds or inpows rh.r@..
<br />md who conracr. ftr such pmirB wirh r Conrrdo(s) li.etrsd luNmi ro th. Codrdols Licc(E L.w).
<br />io!- B, &.-,
<br />I hcr.by atfirft lndcq*nahy of r.lury om ol lhc followine dcclmlhns
<br />-l
<br />have !d will minllin a clfliaEatc of Con$ bS.l Nurc for woi(cF .otr{Enslrio., $ !rcvid.d ror hy SFtion]7m or rlE
<br />L.er Codc. ftr rhc Frfommc oi lhc woft for wnth tlE IEmi k nsd
<br />_l hlr an<l will mimlh worken .orgcBarkrn itr{nmq I EquiEd by S<rhn l7O0 of Uc La6or Codc. for llE Ffornm of
<br />lhe *dk f6, wnich rhis l,.dir is isucd My wo*6 e,p.nsdion insuM. 6k ard Fli.y nunber @:
<br />PolkyNu6b.iJipiB:
<br />-l
<br />ftnify $d in rhi p.rfor@ne of lh. *ort fo. ehich rhir ,.rnir is ir.ucn. I rtull rcl crploy My p.Mn in lnt mMncr
<br />s .i b b.{om subi.tl b lnc eoltc6'comFnsrion hws of C,lifomin. .nd ,gft lh.l if I shoold t eom slb.iftl ro rhc
<br />worlGs conlmerion prcvisbfls of S(t6n 3?O0 oa rhc labor Codc. I slull. fonh*nn omply snh rho$ fovirion..
<br />WARNING F,ilurc lo su. workN'mDwnsdio. .ovr6t. is unln$ful. dtrd shlll subicl an cnplorg lo giminrl rEiahi{ 4d
<br />civn nncs up ro om nudEd thousarld dolla (slm.mo). in addnion lo lhc cosl of n. drroB$ !s lr.vklcd tor rhc
<br />SN'bn 1076 ollh. ttrbot inrcmd and xrorrv r f..{
<br />Oole:--1 /\*
<br />I,IICI/SAIION
<br />I hcEbyafirn utucr pcnaltyoipcrjury lhal I om liRnsl ufldcr pmvishnol Chrplcr I (a,nnmncins *nh Sdion 7(u,l orDivilion l
<br />ol rhc Busincs ald PhfcsionsCodc. ud mylictr* n in full f.rcc.M cller
<br />Liemc Cb$:-LieNc Nunbcr:
<br />l)arr
<br />coNsrBiJc[otitlilulNc-&aDli(r
<br />I h.tohy nrfirnrincr rnalryortcrjrrr rhxr ihcr. n r cod{tocii,n Lndi',! rlcD.y fin
<br />'hc
<br />lcrrontukc olrhc work htr which this r^-rarir ir
<br />issucd (Scc l(I)?. Civ. C.).
<br />ArIUCANLDIICITIX UI,
<br />I hcrc$y alilrn under pcnally ot p€rj!r, onc otrhc tulk,oins decla,alion\
<br />Dcmohiotr Pcrmiri^shc{os Notificariotr frcdcral RcSulnriotrs (Tirlc40. P O
<br />Rcquircd Lcncr ol Norificdion
<br />I ccnilirhd ihc fcdcrnlrcluhlion\ rc8 dirr $tt(os r..rivrl rrc n r r!nlicrhlc h rhisrr.r.ur
<br />/4,."r',,, 'nr , n,'".or,nnapp icxrn,nr nrt rhd rhc rhvc inr{nf ri{r r\.orc.r I r!r.c hcon,rlysihnllL fy (ntrrry
<br />o'dinxnccs xnd srJre Ir$ r.ldinS b6tr'ldi'r! con{tucii,)n. x hcr.hy rcpmcfidivca ofrhk Ciry md Cou.lylo cnkr upon llE
<br />lbore mnrioncd pmpcny for inspcclion
<br /> pDli$nl or Agenl Signntu la-
<br />I
<br />,
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Building Sewer
<br />Area,/Storm Drain
<br />I nterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Piping
<br />Boof Drain
<br />Tub/Shower Test
<br />Bough Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Main 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 ill2t/|KTT'>nqe*v,?3/
<br />Notes, Remarks, Etc.I U I
<br />Water Service
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