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PLUMBING.INSPECTOR RECOHD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hcrcby .,Irm hdcr Ftulry of ledury rhal I m cicryr lbn rlE Conhcton' Lh.trc L2s for lhc folloeing M$n (Se.7otll
<br />Blrincss ad Prof.shn Codc)i Ary Ciry o, Courry whkh rcqutcs a IEnil lo mNltud. all6. impovc. d.mli,h or EPat .ny
<br />rlfude. pri,r ro ft i.!uam, .ho Equircs F .pplianl lor !u.h p.rmi lo nb s ,isrcn slde mnt ihd lE or shc is lic.N.d PlNonl
<br />b rhc phlisions of rL Conk&|or'. Liccnsd hw (Ch!pr..9, Co'mcncinB *ith Sccaon ?000 ol Diviiion I oflh. Busincs and
<br />Pmf.ssio.s Co.lc) or thrt lr or sh. is cxcmpl lh.rciiom atrd rlE hasis ior lh. alkged .xcnpri.n. Ary viohtionofsdlion ?011,5 br.ry
<br />lt{,licanr for s pemn sobjds rlE !ppli.!.r io a .iral pe@lr, ot er @rc the fivc hudEd doll6 (1500).
<br />l. r!.strcrorrhc ptuFny.or mycnr!loyccs wilh*rsc\rslhcn v'h co'n,tNarnn. willdo rhcsork:u lhcsrMrurcnn r
<br />nc cd oriirltrcd forslc(Sc 71uJ. Brsinc$xnd rt,rc!\i{nN C( c Th.Cunt c!tr \ l-iccn\cLawdoc\torrpplyro!no\ru,ol
<br />rlkrniF-ny stu hoilds or mrr.s rtEmn. !ftluho des such wi. iinsclfor hc^clfor rhrorgh his or hcr onn rnDkryct$.
<br />prcvnhdlh such in,l)r(rkmnh m nn inrcfrkd or offccd for \nc. lt hotr cvcr tlt fiiilJi',! or inl|nov.'L- nn,[,sirhin N )(tr
<br />ol'.onucrion.thcOwtr ljuildcr willhrvc rlt hrddtr.lllr6vi'r! Ihrr hc ur \hc dil tror htrili or impr'rc rhc pn,rdy rrtrrtr lu,i,*or
<br />-1.
<br />!sowrcrofrh. pmFny, an.xclorirclyontBcrins *arh lketred.onu.cloN ro mnndd tlr,mj.!l (Sft 7ol:l. Busmrs
<br />dnd Brftsir Cod.: ThcContBcrols Liccn* Low docs nol otply Io ano$ner ottop.ny*ho builds or inr,tmvcs thcreon,
<br />and *ho Nnftcrs for slch Abj&( wirh a C.mEcto(, Ii..ncd ptrnuMt lo lhc ContEloii Ltc6. b*).
<br />-l
<br />! cxcmrl uoderScclio
<br />-
<br />ordr-
<br />IIIBtrEXJI-CAMf,ESAIION
<br />DEILIIBAIIO!
<br />I hcrcby afiim undcr Fnalry of pdjury .nc of lhe following d.cla.iions:
<br />-l
<br />hle 0,n wiu tuinl.in r Ccnifr.t. of Co.e lo S.lf-l.sw for vorl6 .otrpcn lrion. a protidcd fd by Scdi,n 3700 of tlt
<br />t hor C!dc. fo.llE llrflrlllEfu of llr wor!. fr *hbh tlt FmI h h$.d-
<br />-l
<br />hrvclnd*illnui rin woikcr' .onwnearn n inru6nc.. d rcquircd bySccliofl l7(D olrhc Llbot C!dc, for rhc p.tfon,uncc of
<br />h tti\ pc,nir k L*kn. My workm snlEnsdion insurlmc cuicr a.d Fnty ouolE. m
<br />UVJ . \(
<br />-l
<br />ccnit, tliar in rh.,'.rlormnc. of lhc work for which lhn Frmil is issocd. I lhrll nor e6plo, ony pctso. io !tr, frdtut
<br />m s ro bcLonf, slbjc.l lo rtc worts\'comrcnsi' io. hws of Califodir. d a8@ lhol if I sholld lrroe slbjccr ro rlf,
<br />workcF onrrEnslion pmlisions .f Sdrion lT(xJ of llE ljhot Cod.. l dtrll. fonh$ilh coml,ly virt lno* phvl\io.s .
<br />WARNINC: hilurc ro scm {otk.ts conp.nsllion cov@ge is unh*ful. lnd shill slb.icd an cmplorcr
<br />'o
<br />dmitut lcnahics 6d
<br />civil lincs up ro om huidrc{ rholend dollds (SI00.000). in rddilion to lnc cosl of.ohpenslion, da@g$ as Prolid.d for tltc
<br />:::,"iijilT's"Ifflu
<br />I h.6by afllrn uhdM ptMlly of pcrjury that I an I pmvhion olchapin 9(commm ins wilh Sation ?UD) ofDivisio.l
<br />of thc Busincssand PrcfcssioiqCodc. ind my liccn* k ir tull lom and cilcct
<br />Io011t-L
<br />c'".1-(." l;-?.rk .^^^
<br />CANEIAI&I TNIINIUNC.f,AIIII
<br />I hc(byrffirnondcr pcnrlryorpciuyn thcrc is u.oNlruction lcndinslsctrcy ror rhc rc bnmnccofthcwo to, *hi.h rhis Fnnir i!
<br />asucd (Scc 109?, Civ C.)
<br />ATILICANLDIICLISAIIOI!
<br />I no*y rtttn undcr p.ndlry oit'crjuryonc ofthc iollowin8 dccla,olhns:
<br />Dcmolition Pcmrir\ Asbcsros Notin.ariun Fcd.hlRcsuhrn'ns (Tirlc 40. P!n6)
<br />_Rciltrircd Lr(cr of Ndifrdion
<br />I ccnily rhlr rhc lcdcral rcsllurionr rcsadin8 dlx{oi rcmral dc nol 0pDli..hle lo rhls PnJer
<br />Wt.:t',I harc .cad thn lpnltrrn,i ulr skr. rhnr rh. rh,vc inbmurion iscotrccl I ugrc h.orln lt *irh ll Cirylnd (ou.ly
<br />iEs olrhi\ Ciry snd C.un(yt, cnrcr ulonrtrralc tjws rchr ils ro buildin3 c.nnddn,n, d
<br />!ho!c tunrioncd nror.ny for
<br />_*
<br />I P"-r**n"r.rr,r'
<br />'- - : .
<br />Water-Under Iloor
<br />Gas-Underfloor
<br />Buildino Sewer
<br />Area/Storm Drain
<br />I nterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Pipinq
<br />Rool Drain
<br />Tub/Shower Test
<br />Rouqh Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Main Drain/Pool Pipinq
<br />Fill Line/Back Flow
<br />Gas Service
<br />Water Service
<br />Lawn Sprinkler
<br />Sanitarv Sewer/Cap
<br />Back Flow Device
<br />Rouqh Plumbins *l?-5lla/l*7\1*
<br />Meter Release
<br />FINAL t/o14 q\w
<br />Notes, Remarks, Etc.
<br />UNDEB GROUND
<br />Waste & Vent
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Final Gas Test
<br />L.n&l! N.ft:
<br />-4 h4
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