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PLUMBING.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />UNDER GROUND r^\
<br />Waste & Vent I I H!f,,0
<br />Water-Under floor
<br />Gas-Underfloor
<br />Buildinq Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Pipinq
<br />Gas Piping
<br />Roof Drain
<br />Rouoh Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Main Drain/Pool Pipino
<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 7"26-ll L,7'%-t t-trxo
<br />Meter Helease A\
<br />FINAL r -2s-
<br />Notes, Remarks, Etc
<br />01!NOR BUILDER DI,]LCAIIAI'ION
<br />I hcrchy rfinm urdcr I'tmlt! of Frjury lhil I 0 cxcmfl lmnr lhc Conlrldon l,iccne bw fttr rh. t llowin! toln (sc.70ll 5
<br />Itusincss Md Prolision Co<lc)r Any Ciry or Counly *hich rcquir$ d rf,nrir lo on{tucr. alrcr. inil'n)!c, dcNnish or tol[n ,
<br />drucrurc- prh.ro irs Grulncc- alv, rcqurE\ rhc rpplicanr lq \uch Frmir Io filc sigtud {dcnrnr !h!rhcur shc is liccned purrmr ,r
<br />ro lhc rrolnions ol tlt Cntrlractoi Li.cnscd Low (Chrpts 9, CoDnNncifs *irh SccinJn 7U)O or Division ] ol rhc Eusirrc$ Md
<br />Prof.*ion\Gxlc)orrhnrh.orrhchcx. rpr rh.r.rio rMd rhc haris r(tr (h. rllcg.d.rcnllion AnyvblalionolSccrhn70.115hyany
<br />npflicrtrrbrar{rnrirsrhjcclsthc.ptlicrtrrto0civilpctr.lryolmrnrcrhmfivch!fflrcddollm(5500).
<br />-I,
<br />* owt, of rh. prcFny, (r n, cfrplorlca wilh va8cs N their nn. 6'qrcns.lion. wiU do llE eork !d tn slftl@ is ml
<br />intcnded or oficrcd lor elc (SN.704.1. Busircss lnd PFfssiotrs Codc TIE Co.rrr.r6ls Li*ns Llw .krs ml .pply lo e owmr of
<br />lnc pEtxdy who builds or iq,mrcs rh.mn. od wlm do* ssh M* himsclf or hcrclf or ,e!sh th or her own .q)loy.cs.
<br />Fovidcd rtsr rkh inpdEmnk amt im.,it d or olftrcn for slc.lt h.wE, tlE ttrildirg or inpffimnr h $ld euin orc Ftr
<br />of odphthtr rh Owncr Build., sill haw th. bldcn or t,sving lnlr hc or shc did ml build or imtmk rhc !reFty fo. itE purlDs of
<br />-l,asowmrotrhetmpcny.!meiclusivclycorhcrirywnhli.cnsdcontr.erGhon{errlrF}f,t(sc.7u4.Busncsrdd hlltsionC6dc:ThcConi[croasLi...rchwdoesnorarplrro!nowncrofpmp.nywnobuildsorimr,mvcsrhcrcon.rnd who mnimls Lr such,rmjccrs vilna Conrdo(t lt.nsn,rlrsulnr ro rlEContrcrors Liccne L!{).
<br />woR([tls, coirPrNsaTtoN
<br />DECI.ABAIION
<br />I turc$y !fits undcr penahy of pcrjury orc of Ihc folkrwin8 d.clmlions:
<br />I havc !d sill tui. ain r Ccniaf,0tc ofcons lo Sclf- Insur. for tuikcs snlEnsr ioo, 0s pmvidcd for h, SErion :1700 or lh.
<br />Lih, Codc. for rhc pLraorodc ot rhc uork t r which rh. n mir is issucd.
<br />-l
<br />hovc lnd I ill mainruitr wortcs conpcnsarion inslmmc, os rcquted by Scdi.n l?m ol lh. L0bor Codc. for lhc ll.rfomre oI
<br />Poli.vNtrmh.r: Ern
<br />bLl.cdrlyrhrrnrh.nrrhrrumcnrrhc*,trklfltrh'chrhi\pclnirisissrcd,Ishrllnrcnpk,y y p.rv inrtrynuncr
<br />/ a, .^ h' hc!.dc \ubJc n,rhr*u*r^.-nf.n. r.n hwsorcnrirrmir, lnd llsrcc rhd ifI rhould bcco'rc sunjcci lorrr
<br />wolkcr' .omFDsarh ,rovisions ol Sc ion l?00 of rlE Labor Otc. I nrll. lonhwir h comply virh rhot F,visio.\
<br />WARNiNC F,ilurd r' $.urc aortcs con{.ns,rion.o nrbj.c' !n cnrploycr lo sihiul ltMllics and
<br />conrp.nsiriotr. domBcs 0s nn,vid.d lor rhc.ivil nncs ut ro onc hund(ll rhoxsnd dollr^ (51
<br />".,,,<q/b/ ta
<br />^l]Iirt tlljtat
<br />I hcEhy lfirm uMs plnally of pcrjlry lh l am liefl$t unds Eovhion otc!.flc! 9 (.nnwNing with Sera'. ?000) ol Division l
<br />ol ln Busims md Pmf.siotu Codc. ud my ltcn* t in tull lom
<br />,*",--Jf2t-/1 X,,-"*,"
<br />IAdfiIf,II.:II!)!I,DNI2INC.AJJINI:I
<br />I hcrh, rflnmrndcr I(ulryorNrjuryrhd rhcrc ir r.on{fl.ri,i kndiis rerncy n, rh. p.rro,ntrrcc ofrhc $rk tn shich rhn Fnnir i\
<br />hsu.d (Scc.l@7. Cir C ).
<br />AIPLIIANUTECIAAAIION
<br />I h.E$y afm lndcr r'.nolry ofFrjury onc olrhc fduownrs drlualn,nr:
<br />Dcmlili.n PcnnirsAsbcsros NorificarioD Fadcral Rcaularions (Tirle 40. Pon6)
<br />-Rcquncd
<br />Ldtcr of Norifi calirn
<br />-l
<br />c.nify lhlr rhc lcdcrul E8!,lrions Esadin8 lsbcslos rcmvd d not ryplic!$lc ro rhis rn'Jc.r.
<br />I .cdif, th8r I hNr rcril rhi\ rI ion d srarc rhd ihc ab.v. i.rorn ion is coNr I asre ro on 'ly wirh lll Ciry aod Counry
<br />ordi'ktrc.s rxl Sirrd liw\rehriis huildinA ..tr{d.rnrn. dd hrrchyaurhorizc rcll$cnr ivcs of rhis Ciry atrd Counry b enrs ulr)d rlE
<br />trholc mnl ioncd tmFny for
<br />H t-z-O ) t ,crI
<br />^,;7/il18
<br />ITSD)
<br />tr7zc*
<br />Tub/Shower Test
<br />Final Gas Test
<br />-l
<br />um.xcml,l undcr Sdion- lr. & P.C. forlhisrcoan
<br />D.rc. Oqm.:
<br />.od0c.!dion inslr'm.Mi.r od Iblhy nunbcr N:
<br />70tlt1(,"(r,ii<:
<br />ta*lo s Add,$+
<br />-
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