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PLUMBING.INSPECTOR FECORD
<br />APPROVALS DATE ID/SIG.COMMENTS oWNER AUILDI]R DEI-CARA'I'ION
<br />! hcrchy alfinn undcr Ftrilry .l ,)cryury r hd I rtrrcxctrU liorn rhc atntrrloF l,iccn\c ljs f rhc folk,sii3 rcdkr lsc(.rl).11.5
<br />8u(ir.$ rtrd Profcrsi(,n C,xlc) Any Cily or Counly which rcquirc\ ! p.nnir b con{rurr. !lr.r, mptnc. dcnmlinr fr rcFn rny
<br />nn'crurc. priqfu irs hsulncc. !l{, rcquircs rh. apllicur for \uch Frn r t, filIn ilncd nnrcnrm rhd h.or \hc is liccnscd lunnrnr
<br />l') rfu tlo\isions ol rlE Cotrrmcktr s Li.cnsn Lrw (Cl prcr 9. C.Nnrncing sirh S.cri{n! ?(XX) ol Divilbn:l olrh. Au\incss 0trd
<br />pplirair ntr r lrrmir \ubjc.h rhc {tli..Drroa.rvilNnilrtornormr hanfivcnundrcdd.lhrs($5fl))
<br />_1. &r ow*r of E poFny. or my .mplo)rcs Bith w.gB er ih.t $k Nnpcnrlrior. Qill &r dt wrt lid d. ms@ b mr
<br />intcnd.d or ofimd for slc (So.7044, Blsituss aid PiDfissions Cod€: The Conracln s Lic.trc Llu do6 not r0ply lo m o*tr( of
<br />rhc I,qrnrylb toitti or inirnB rlt@L dd sho &xs sh ert hi@lf or lEElf or lhrcush his or hcr o*n ctuploF.s.
<br />povid.d lhsl 3uch impownls @ ml inlc,icd moff.Ed ltr sh ll ho*E lh. boihing or inpmrcE B$Hwnhi,onc,€(
<br />ot@lpllbn rl* OeF Auilts wi[ n w dE hrdcn orFDvirg nd tE q JE dn d hoi]d or irymE dr P,oFry for tli F leof
<br />-L
<br />asownfiol$c prolcny. sm.rclusirclyconrocring virh lianed co ado6 ro consttu.r rh. rojccr (56.,(x4. AusE$
<br />ad P,ofc*im Codc: Tlc Conreroa. Lac.nc tl* dft3 mr .pply 16 rn o*mr or pmpcdy who builds or intmv.s ltErcon.
<br />! d wno .o a.ls for $.h pmjcclx with ! ConlEclo( 9 liclo$d pursla rorhcCo radois Liccn* kw).
<br />l rncrcmd undcr Scrion .B &PC fu lhir e&sn
<br />woR(r'tas' coMPnNs,{Tl( lN
<br />DECLAAA.IITIN
<br />I hcrchy afftr m undcr pcMltyofnc4urynm ol ll* fnllo*in8 dNlmriotr.
<br />l4l hrvc ud wr ll mmram ! Ccn'rEab ot Conenr ro Scla.ltrslrc for k*6 omp.Bdion.ar prcvid.d aor bySalion l70o oflhc
<br />r-a-trr Cr*, ror rtr pcrormrc of lhc wo for qtich rhc I.mil nisued
<br />_t h!v. and sill mjndn *orkcii .onp.nslrio. insuraec. a. Equircd by Selion 3700 of lh. ljboi C.d., fot lhc pc.toro1m. or
<br />rhc work ror whkh rhis p.mir ir iss.d. My work6. .or{Ensdion n$mmc cMis ed policy n!mb., &;
<br />,{r.... L-, O -e-,+.-, cr.s--lts
<br />l),t(o
<br />Vt .eniryrh.r in thc pfffo.mmc oarhc *ork for whi.hrhisp.rmir is nsu€d.l shlllnor erpbyrnypeen io a.y msnrcr
<br />$ as lo t sm subj.lr ro rhe *o 6'.orwn.ljion lrws of Cllifomil andagftlhd if I slbsld b.{om subjcd to lhc
<br />*orlcrs' srrnetion lovnions of Sdrion :!700 ol rh. Lihor Codc, I shdl. lonhwnh cotrply sirh lto* Pmlistuns..
<br />WARNING: Fsilurc ro $fu erl6 on!.ns{ion 6*E8c n !.kwtuL rd sn,ll subiet e.mplorr lo dimind ltMllts &ld
<br />civit fincs !p toorc hudEd rhoulld dolle (t100.000). an addirio. ro 0r co of onpcnsalion. d,tug.r I|,rcvidcd tot lh.
<br />lBrion 3016 of rh. L{tor Cod€. inrest a.d alt)my i fci.
<br />DECIJSAIIO]i
<br />I hcrby aflinn uMcr rc6,lryofpcrjury lh.r I0m li.ctrin undc.l,ovisiotr olCtlpl.rr) (conntun.nrB snh sccrion 7ux) oiDivhi.n.l
<br />.l rn! Businclsaod Prrc$i,nsCodc, arii nrylhcnc i\ in tull forcc d cli6l
<br />-Jo'<t-rr.-
<br />L til,{-,.\ (-
<br />l
<br />g}I!IA!qUO!,IENDINIiSGDggI
<br />I hcrcby aftun lnd€r ltiahl ot tidhry rh lhce i. a onnruction lcndin8 n8.ky for lh. pcrf{r]rurcs otllt*ork for whkh$n Frmil is
<br />is\ucd (s(.1097, civ. c.)
<br />AIIUCANfDEII,IIAIION
<br />I)rrhyafimu6dcrF-nrhyof pcrjuryoncoiihch,lorinSd.cl rlnnN
<br />&mlirio! Pcrmilr A\tf,nos Nori,i.ari,)n kdcrnl Rcgultrhn\ Gnlc a0, PMO
<br />R.quncd btr.r.rNotifi dri,n
<br />-l
<br />ccn il, rhlr rh€ fed€ft| Esrilarionr Egatdi.g ,slBtx rcfr,ldl m nol rrplicablc lo lhis l,mjecl.
<br />I .diry rhdr I Mvc 6rd rhis .ppli.srion 0d srarc rhd rh. .trw i.fomtior is co,rc.l I lsre ro onll'ly wIi trll Cily ,nd Cou.ly
<br />odina.c.s and St!r. t ss sl"lin8 ro building coNtruclion, md hcrcby aurlFri4 rcFc*obtircs .I rhh Ciy and C.u.ty !o cnr6 upon llr
<br />ltxrrc mnri,)rcd Impcny tr insp.crio. p!4i{s
<br />Appli.{nl or Aeenl Siamlu -,.:Zltl/,Jq
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-underfloor
<br />Building Sewer
<br />Area,/Storm Drain
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Pipinq
<br />Roof Drain
<br />Tub/Shower Test
<br />Rouoh 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 />Water Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back FIow Device
<br />Rough Plumbing
<br />Final Gas Test
<br />FINAL t///ft ;^ Kb
<br />Notes, Remarks, Etc.
<br />412-qltR
<br />-,.-', {tr(16
<br />Gas Service
<br />Meter Release
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