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PLUMBING.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELC]ARATION
<br />I hcrcby alIrm lndcr o€nslry of rsiury lhd I m crcnpl lmn th. Conslm Li.rcn* Llw fo. llt follosinB E&so (Ss.7011 .5
<br />BBines !d Profession Codc): Any Cny or CNfiy vnifi tquiEs ! IEmil lo @n$ru.l all6. inpmk, d.mliih or qEn e,
<br />structurc. prior b ns n$.ra, .ho rciuircs lhc sprlicanl for Mh I'mI |o fib 3 siSned nllcmnl ihat lE or dE ir Iimn$d puNail
<br />ro lhc Fn"isios of tlE Co ncl6l3 Liccn*d Lae (Ch.prc, 9. Conmrcing wnh Scclion 7000 of DiviskJn 3 ol rlr Bximss a.d
<br />PDlc$ions Codc) or rhor nc or sh. is sxcnpr rherciior .nd rhc bosh for rhc {U.E!d cxcnprion. Anyviohlionofs.dionl03l,5byany
<br />uotli@nt for a pcmn robiFrs rhc rpplicanr lo ! civil pc.llry of mr mE lh& firc hundcd dolbs ($m).
<br />-1.
<br />c o*er of thc ptupcny. 6 ny cr!,lores with wigca a. rh.t sh @mFlerion, wil do tlE wdt !d tlE $iete b hl
<br />i cM.d or oflcrcd f6 sle (Se.7044. A!!i*$ od PEfc$ioo, Codc: 1tc Conlreclor's Lkctre Llw do6 not qptly lo a ownd oa
<br />rlE F,Fny vho huilll tr inFreB rldatr .rd ano doR tuh m* hin*r or lEMlf or llhlsh his d id om cnplort.s.
<br />pbvlhd lhar sch inlmlEmnls @ mr inrcndcd uofcrcd aor *lc. t[ tr*wr llE building o inprcwm.l is sld *ilhin om Fe
<br />ofo'riEtion. d. OwM Builrf oill h{E th. h,rh. otprcvhg rh.r h. 6 ilE dll rpl buiu or irpltr 0E FoFry fo, tlE Flrrs ol
<br />-1.
<br />d o*ncr of rh! nmp.ny. aor .rclusivcly co.lBclirg wilh liccnscd conlracloB lo .onsmd llt lolcct {s6. 7044. Busrms
<br />md Pioassim Codc Th. Conrruroas Liccnsc L.* des ior apt ly ro d ownr of proEiiy who builds or iq,mEs lhcron,
<br />,nd who @nr{ck for .uch pmj.cis wnh e Conrnctods) Iie.*d l,urunr ro rhc Conmdols Lienlc liw).
<br />I anr.r.mnr und.r Sdhr .B &PC forlhhE.{n.
<br />Drl.: ()*t.t
<br />IOBf,EBS:IOMTEIIAU!.N
<br />DFCI ARATioN
<br />I hcrcl,y cffinn undcr p.nalryotpcioryotu oftk followiig dtlMri.nl
<br />,r- I hnvc ud s r ll mintain a CcnrlEarc uf Chn*nr r. Sclf lnrue for erkcB $mp.nsltion. ns providcd fot by S<r ion l7m or (hc
<br />/ tib.{ Codc.ln thc rErrormne ollh. wqk r({ *hkhrhcIlcmi n n$cd
<br />-l h{vcond will minrain *nrlcrJ con'p€nsrrion insuratuc, us rcqutcd by scdion 1700 ofthc Llhor Codc, for rhc !.rromum. of
<br />rhc *ork {orwhichrhhpcm ir i$udl. My workcB conpc.ssr ion insumncc caricr ud plic, nlmbcr @:
<br />1Wl7 (t,tto
<br />q r -1
<br />-l
<br />cdnif, lhnt in rh€ lciforroftc olthc work lor which lhh pc.rnir is irsucd, I shtrll nor cmployrny p.ison in lny melrcr
<br />s as ro t8om subjccr to rhc {orkdC conp.nerion hws or cllifooie. ,nd a8N rhd if I stblE lEcotu subiu ro rtE
<br />sorkcl .ompcnsarn,n povirioos or Sslion l?m ofuh. tjbo. Codc. I sh0ll. fontwith coryl, virh rho* novisio.s .
<br />WARNINC: ljailurc b ecurc solt.* comFndn,n .6vcmB. i\ unhwful. lrd sh6ll suhJccl !n e,npk,y$ !o dihin.l pcuhi.T ond
<br />civil uncs up lo onc hund.cd rhou\r d dolllr\in Mdnion ro rhc cosl ofcodpcnsllio.. da@lcs !s pmvidcd lor lnc
<br />Sc.rion 30?6 ofthe Labr c.ne- inr$csr Dnd
<br />D!(l-&ut!Jr
<br />I hcrhy drfird uidcr l.hrlryorp.rjurr rhrr I liccnBl undcr pnvtiotr ofChrtlo 9{conmn.ing wnh Sccliotr ?000) ofDiviiion:l
<br />ol rhc Busidss a.d Pmfcasio$ Codc. od my lkcns ig b full foN o,n cfiec-
<br />e
<br />c()Ngral]cu0xrllDllri-&GErtr
<br />I hcrchy.rfiiin unr,cr 0,n0llyol pc,jury lfilr rturc h !.oisrdcri," lcoding ngcrcy lor rhc lcn'onnmcc oflhc worr ror *hi.h rhis Fflnil is
<br />iriucd (Sc...l{lr?. Civ C.).
<br />I .cnirt lhar rhc rcdcr0l rcgulol iotrs EsrdinB ostEnos rcmral uc nor sprlk$lc ro rhis tmFI
<br />-l
<br />ccnify fiar I hlr tcad rhh ,I kal ion &n {alc ln,t dE lhw infomlion k comcr, ! asIG ro @nply wilh all City snd Colnty
<br />itui..s rnd Srur. Irws 6Lr ine n)ildin8 con(rudion, ad hcrcby,urhoriz. r!'r.scnHivcs ofOt Cily and Countylo enld Uon lL
<br />w mnlioncn pml.rly for
<br />Applienl or A*.nl Si*nrltr ,,,r,1/s-:Jlt
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Building Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarilier
<br />TOP OUT
<br />Waste & Vent I to f.b
<br />Water Piping g'l'ru \vTql
<br />Gas Pipinq
<br />Roof Drain
<br />Tub/Shower Test I \il-+e t '{hrrla-t<'L,z'
<br />Rouqh Water Heater "-t"
<br />POOL/SPA
<br />P{rap/Drain Line
<br />Main Drain/Pool Pipino
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Gas Service
<br />Water Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />Bough Plumbing tthfir vn(wt-)o,
<br />Final Gas Test
<br />FINAL tthl k €.-n4rr*/ 6-2--
<br />Notes, Remarks, Etc.
<br />Meter Release
<br />-*, a120L4
<br />+
<br />txndn !
<br />^,J&.r\
<br />-
<br />ADPLICANT Nf.CI Af, ATI(IN
<br />I hcrcny.]lmr undcr pcn0lty olpcrjuryonc oalhc nnbsins dElararnrns:
<br />Dcfrririon Pcmir$Ash.sror Nor incarion ft'lcral Rc-qul0lioDs CTirlct0. run6)
<br />-Rcquncd
<br />Llkr of Norifi dion
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