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PLUMBING-INSPECTOB RECORD
<br />APPROVALS DATE COMMENTS OWNER BTIILDI:II DEI,CAI' TION
<br />I h.rchy anirr un(lcr Fnrlr, {)a lf,rjury rh, I In crc'.pr lhd rhc (innn'.rnJ Li..nsc tjw for rhc following rcr$n (5(.?011.5
<br />Busitu$ md PioLsnrn C.ih) Any Cily or Counry whi.h ..quncs r lErnir ro con(rud. llrcr. idpn,vc. &fr,lirh ot Epln atry r-
<br />{rudurc. lrnn ro ils issutrtrcc, nho rcquncslhc o,,plic:nl fo! ch Fr.rirb nh tr siEn d lrd.mfl rhrt neor stu is licenBd Pusuanr',
<br />x, rh. pn,viionr otrhe Cookr.rr \ Licciscd Li{ (Chdtr$ 9. Cinn En.nrp Nith Sc.lion 7O(() ol'Di!hi,,n.3 olrnc Burnrss ard
<br />Piirfd\\n,orCodoorrharh..rsh.i\crc.rrrth.rctiomu thrhalisf.r rhcul[Bcdcxcm ion.Anyviohlionofsc.liD?0]l5bydtry
<br />!t!pli.r( ror r pcmrir suhjLrk rhc applicanr bn.ivilpc.!kyornor nFrc$an rirc hundrcd dolln^ (S51x))
<br />-1.
<br />&s oser of lh. pol'nr, or my coplo}!€s {nh Mgcs &r rhcn $b conp.n..rion. will & llE wst srrd lhc tn$@ h mr
<br />inro.Ld orof.Ed for elc (Se.1044. Ausircs ed ProfcssionsCorlq Thc Co radoas Liclns Lra da rcl rplly lo s owrcr of
<br />rhc prclany eho boiUs or iqmB dEpn. 8xt who dcr sh s* hiNclf oi lEall or thmugh hir or hd o*n cr{,loyt6.
<br />provilcd thll s!.h inpmwils N ml inlcrk d odcrBl for slc.lt bo*m.lh. tDilding or itr{,ftftin t eld qhni. onc rE(
<br />.f orpLriol! dE ol,m Built . wix lEr tlE hrd.n ol Fotire hrh slr did rcl hlild or inprorc thc polsly forlL tEIEEof
<br />-1.
<br />os ouncr .f Ih. I,mr.ny, !m cxclusiely onrEctins wnh liccnscd onrrror $ sn*ud lh. IJmro.t (Scc. ?044. Bosimre
<br />lrd h.l6rbn Code: Thc Conreior\ Li.cnsc L{w d6cs nor amly lo e own.r ofprcp.ny qho builds or improvB rhomr,
<br />and who onrEls aor sBh nmj.{rseirh i Conlmto(s) Iiccnscn rusoair 16 rh. G,nt@rol3 Ljen* tiw).
<br />I mdcmd undcr SNli,n ,A &PC forrhn,lMn.
<br />UOBf,ETS:(OMIE!'AIIQN
<br />DECL4NAA-rON
<br />I hcret , s,firm undcr pcnalty ot pcrjury orc ofihc loU.wing d6l@tions:
<br />-I
<br />hrvc rrd eitl minlain . C4nifrdc olconsnt ro S.lt-lnse for qortcs oq,misrion, s poviled for by S*lioi 3700 01lh.
<br />kbor C.d.. for rlr pcrfolmN of rh. *orL for ehich thc ldnn i! hrEd,
<br />-l
<br />havc and qill mifllin qorlc,s compcnralion imu.Ec. s EnuiEn by Scl k'n 1700 of thc tjbo. Codc. fo, lhe ldollMc of
<br />rne qort lor whkn rni! I.mn ii h.rcd. My workos' oqrN,tion iBtrmN cei6 dn polcy tunbcr @l
<br />-l.cnify
<br />lhot in lhc performmc orlhc qork for vhich lhis tcrni ii nrkd.l $rll ml.nrloymy P.rsn in any truncr
<br />s ar ro tt..m suhixr r. rhc work ^ con{EN{ion hws orcalirorni!. md !8rc $at ifl slhuld lEtonE sub}ld ro rh.
<br />*orkcB ompcnsrion pmvhions of Sclion 3?0o of lhc bbor Cod.. I shrll. fonn*nh smply eith lhoc PDvi.ions .
<br />WARNINGT rrilurc k, surc workcn' coqcnsarnn oycrdsc n unhstul, dnd shall suhict an lnployct to riminal [arulrt\ md
<br />civil finc\ up h onc hlMrcd iho!\aftl dollrr lslm,(Xn), ii ro rhc .os of cohFns.rion. d.tu8cs os p,orilcd lor llE
<br />Sccttun 3076 olthc kbr Codc inrcosta.d
<br />l!]j(!tltlllaN
<br />I her.6y .fli.n undd F.aliy of p.rrury lh.l I @ li..nsd uids Fovirion of Cnlpld 9 (onmrcing wifi Sdtio. 7000) ol Division 3
<br />of $. Brsift* ,nd P'of.$io$ Codc. !r'd ny liccEc i. ii tull toE. Md .lIal.
<br />cd'ndor 1 )t\=(
<br />CONIiIBI]CIAN.L! DIIG.ACINII
<br />I lrEhy llfirnr un,lcr Fmllyoll{irtryrhd lhcrc n ! cotr\rrucli(in kndin8,8.n.y ror rhc t'.normmc oflhc $ort lor *hich lhis Frmi' n
<br />hlucd (sN :109?. cir c ).
<br />APII,ICAII.DECI.ABAIION
<br />I hs6y aiim uflds Fnalry of pcriury of ot tlE follo*ing dc.hnrio.r:
<br />D.,Flition Pcrnih-Asbcsros Norificlrion F.n.d Rq:rlalions (Tirle {0. Pai6)
<br />-Rcquircd
<br />Lcllcr of l'lotinculion
<br />Iccniryrh l h.vc r.nd rhis apDlic.rion 0 shre rhal rhe ltovc informrion h cor<t. l rgre ro con ly qirh sll Cily ard Counly
<br />ordinrnc.s ond sr.re tiws rcLrin8 ro brild rcprc*nlariv.i ofrhh ciryand cou y ro enrs upon tlE
<br />nh,v..rnri.n d pol)cdt n)r
<br />Applicml or A$nl Si*ndluF:
<br />p"*n-** rpa,o' G4rr'.'-E J L
<br />,*,",ey'u/N
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Buildinq Sewer
<br />Area/Storm Drain
<br />lnterceplor/ Clarilier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Pipinq
<br />Rool Drain
<br />TubiShower Test
<br />Rouqh 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 />Water Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />Rough Plumbinq
<br />Final Gas Test rNZrug re)
<br />Meter Release Uh
<br />FINAL qh a'nm.+t<4s)1r ,u,1Notes, Remarks, Etc.
<br />ID/SIG.
<br />5lrllul(
<br />Policy Noob.i =rpics:
<br />-l
<br />..nify thar rlr tcd.Bl Eguhlions Bgsrding !sb.s$ Enn%l rc ml q,plicablc lo lht lmlf,r,
<br />tl
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