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PLUMBING.INSPECTOR RECORD
<br />APPROVALS DATE OWNER BTJII-DER DI]I-CARA-TION
<br />I hcrchy afftnr undcr pcnrlly oi Frjury lhil I0 cxcnrl rinrn rhc Cont.crors Liccn$ I;rp fo h.Iollo$ing rcasn (Scc.rlr.1l.5
<br />8u\inrs\ ! l Pofcs\ion Cdc): An, Cir! or Coulr, $hich rcquircs r rErmil lo c\Nlrucl, llrer. nnprovc. &rnoli\h r rcF't rny
<br />qtu.turc. pri{,k, ir\ n\utud. al\o rqliE\ rhc lppiicr tor {uch Ilcn.ir ro filc a s isncd (arcmnr rh hc.rshci\liccn\cd,usulor
<br />ro rhc [ovnn,ns ofrhc Contr.crois Liccnscd l-rw (Chrpr.r 9. C. nnrn.inS sirl S..rn ](XD of Divi\i(r I oll[c Bu\inrs rid
<br />Ito|c$i,)n\ O'dc) or Ihrr h. or shc ir cicflU lhcrclrorrtrd
<br />'hc
<br />hr\i\ fortl..rllclulcrcnrrio AtryvnnddrolSccrinrT0.ll5byrny
<br />rtpli.rnrrorrpcniir\uhjc.(rhc,mli.rilorcivillctrlllyolnolnxtrclhrtrfivchlnnrcddollln(St(D)
<br />-1.
<br />!s owncr of the pmtErry. or my cq)lotrs wilh w!8.s as lhcn sb compcns0lion. *ill do tt* wdt !d thE slru€lh is ml
<br />i e.d.d o. oflced fd sal. (Se.7()44. Brsines .nd PDlcisions Codo Thc Contmrry\ Li.d* kw des mr opdy ro s ow*. of
<br />rh. roliny *ho toil& or in{mEs llEmn. lrd who &B Mh w* hifrc.lf or hc*lf or lhml8h his tr hcr own enployc.s.
<br />Foridcd lhal Fuch imlrcrcm'rs @ ml htcfl,.d orotr ndfoisb.ll'. how. tlE buildiqg 6r i,rircrcftnr i!$B uirhinokJ&
<br />ofo'rplcrio,r. dE Owmr Buil!, wi! lEr 0F hldo olrnring rh.r he or nE dit mr build or hleE th. trofoty for tlr putoc of
<br />-1.
<br />as owncr of lnc pbpcdy. m cxclusiEly .onhriae sith li.cn*d conl6.ro6 16 @nsrud tr ,&j<r (Scc, 7(x4. aE@(
<br />and A$fi$imCodc: Thc Coniruct sLi.enscLowdoesnoralrlyrouowncrofprcpcny*hobuildrorimprolesrficr€on.a.d *ho.onlEclsforshpmic.lswilh!C,nlEdnrls)lien€dpuNamb'h.Conrdor'3Ltcnstlw).
<br />-I
<br />om .renfl undo Sdrioo . B. & P.C- for rhh rcasn
<br />woR(E&s. c()MPEttsaTioN
<br />DEClrlf,A.trON
<br />I hcEby alilrm und$ penalty of p€riury orc ol lnc followinS delarolions:
<br />-l
<br />hrvc mdwill m0inlrir trCcnlfictrlcolConscnr b Sclr ln\urd lor w.lkrtr co'npcns,rion.0s nn,vidrd r(, by sclion :17fi) .r rlE
<br />lrhorCddc, r(trrhrFra..nrn.cdf
<br />'hc
<br />*or* n,shichrnc pcirnir i{ tsucd
<br />,X(rcandNrlrmJ r0 wnrkc^' cnm|.nld 'nn nurri..,!r,.qxirdh,seli( 17fi) or rhc tarxtr cod.. r{r rhc l,croniuNc or''hctr,{tn{tr[ichrhr.tErmir\hucJMytrml$o,nl|.n{r'.ii4!dEiu.rsR,fi]|Uliynumh.rr.
<br />',". Po'lq4a.r*-
<br />I c.rlify rhar in rhc pffortunc. or rhe w.rk {D. shich rhis pcrmit is issued- I qh0ll nor emphy anr lcnon in aiy manrr
<br />s &slolEconEsubFcllorh.wo sc smFnsalion hM otc.liiomi4 and $M rh.l if I shotrld tf,.om subjcc' roln
<br />workefi comFnslion pmvisionsofSetion 3?00ofthc taho. Cod..I sldl. aodhwnn of,rply *ilh rhos! pmvhions.
<br />WARNING Frilurc to surc workc^
<br />civil fincs up lo onc nu.dr.d thouslnd
<br />n unh*tul. anil rhJl \nhj(t trn cmpk,ru o oininll tfohas Md
<br />ddirion r. rhc co{ .l .ompensal io.. damgcs rs lrovidcd for rhc
<br />u!],lsIl)_rcNrr (ja-8
<br />Igrr4-tsdl,I12!
<br />I hcrcby rlfirn undcr Nnallyolpcrjury rhlr l,r.licctryt uM.r a,ovi\ion ol chrptcr 9 (comnrnrS lith Scclio. T(tr) olDivision 3
<br />of lhc Ansinc*atul Pmfc\siJnsCodd, dnl.ryli.ci+ ii in tlllli,rcc dcq(l
<br />17qSBe>G
<br />q)Nliln.tilll()NLf,NDll$rlli[NrI
<br />i\su.l (Sc. .ll)97.Civ C )
<br />ATTUCANLDECI.AEAIIIIN
<br />I hrrry Jrim undc! lcnalr, ot !.rrury nrc of lh. follo*in8 d(hrul ions:
<br />DcnDlition Perniu-Asbcnos Noliic io. Fcdcral Rcguln'ions {Tn].40. Pd6)
<br />-RcquiErd
<br />tl(lcr of Nolifrllbn
<br />I ccnily rhll $c tcdcElrcslErions EsrdinB asbc$s rcmlo, !rc not npi'lic0t,e lo rhn poj.rr.
<br />I ccdifrlhrr I hlvc md rh(,ppli.rrion xl $dcrh r rhcrh,vc i.lnrnBrion nco tr Iagrccb.. ll)ly virh ill Ciry ,nd Coutrry
<br />ilding connrudio., dr<t h€Eby rurtsrir. ,cplc*nrdriv.s or rhis Cir
<br />4->
<br />,:;/;;Z;
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Building Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarilier
<br />TOP OUT
<br />Waste & Vent
<br />Water Pi ping
<br />Gas Piping
<br />Roof Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOL/SPA
<br />P-t raplDrain Line
<br />Main Drain/Pool Pipino
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Gas Service
<br />Lawn S prinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />Rough Plumbing
<br />Final Gas Test
<br />Meler Release
<br />FINAL {,ft,T116 9D6d
<br />Note Remarks, Etc.
<br />ID/SIG.COMMENTS
<br />Water Service
<br />Lf,ndo r AddN.r
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