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PLUMBING.INSPECTOR RECOFD
<br />APPROVALS DATE tD/stG.COMMENTS OWNtrR BTIII,DER T)ET,CARATIoN
<br />I hcrchy r,ft und$ Nrdry oi pcrjury rhd I am drc'npi lio'r rh. c(rnrrcro^ t-ictrsc bw fd thc follosin8 rc{son (Scc.7o:ll5
<br />Dusinc$ and ttofesion Cqlc) Any (iry or clMry *hieh rcquncs ! r.nir ro .on(rucl- alrcr. impro\c. dcmolnh or rcplt !.,
<br />dtucru(, pri{rro ir\ n\u!icc. ako rqut \ rhc lpnltlnr Lrsuch pcrmir ro lilca siln.d ndctunr rhd h.or \hc is li.ctrscd tur\uMr
<br />n) rhc Itr,vi\i{).s ol ilrc Conlrlcloi\ Li.cr*J l-ls lCh.picr 9. ConnncNnrE with Sccrn,n 7U)0 oi Divi\i('n .l ofrhc Btr\i,1cs rtul
<br />Pdcssions codc)orrhi hcorshc,scxcmfr rlfotb mdrhcba\i\forrhcrllcgcdcxcnuion. Atry volnriotr of Sdi,n ,0:l I 5b,utr,
<br />ap!licanr ior o l{rinir subhctr lhe !tpli.rnt 1o aciviltcnrlryoinor mrcrhrn iivc hundrcddollsrlS5O0)
<br />-1.
<br />a{ ow@r of rh. Fopcfly. o! ny emplo}rcs with wagcs N rlE sh ohFnerion, willdo tr wo* and ltE slrudE ( ml
<br />i ended o, offrcn tu eh (Se.7044. BEie$ md Ptorc$ioG C.d.: TIE C.nrador! Lt.@ tjw .locs mt lpply ro u o*er oa
<br />rk poreny wlD builds q inviDB dEdi. atld *lD dG Mh w,t hiNlf or tcmlf or rhreugn ht or h.r osn crplores.
<br />,,Dvidcd lhll such iqmtlmnk d ml inl..(h n otr r.d ror sh. ll howE itr bilding or itrproEmnl is sld within orc )at
<br />ofcotrphlior. 0E Owrcr Au&tc, wil h{E tla buden ofprcving rh{l tr o..hc dil ml bulB or iqrcw t pmpsry for drc purposof
<br />-1,
<br />as owmr oarh. pbFny, m cxclusi4ly contocling wirh lic..sed conlmcloc ro conslruct ttf, r.mid (S(. ,044. Eurin6s
<br />drd Ebfcsbo C6dc: Thc Conrsctoli Liccnsc Li* docs nor anply ro on owiu o( p.6Dcny who builds or inprovd ihcr.on.
<br />and who conrEcls lor such l,oj.trs sith r ConlEcto(s) ,iro*d r,uBMr ro rlr Co rertr i Uae Lre)
<br />WORXr.RS' CO}IPENSATION
<br />DECLIBAIION
<br />Iicrcby alfi, uider pcnallyofpcrruryotu ofrhc followiflE d(lsolions:
<br />-l
<br />hrlc !'n *ill minrain ! CcnifEdc of Conent ro Scr'lnsurc for wt6 ohDetr*tioi. &s finvil€d lor by Sdion 3700 of rh.
<br />Labor Codc for lh. Frformnc. of th. wort fm vhich lhc Fmn is issBd.
<br />-l tarc ud *ill minllin sork€si con{,cnsalion insuramc. .s rcquted hy Sal n,n :1100 ol rh. Libor C.dc. for rhe pcrrommc of
<br />lhc q ( fot qhtt lhn l.mn ir hmql My wo,k6s ompcNurion iasumN.aicr &id Fli.y oun$c. m:
<br />(os
<br />(3r!.JV Co la{d?o \.\,\4.
<br />I .cnify innt in rh. p.rfor@m of dc wort for whi.h lhh p.toil is issucd. I shall nol cmploy an, F6on in ony mntur
<br />$ as ro bcsm subjccr to rhc worlca'(mpcnsrrn'n hws ofcllilomi.. &d rEttc rhur it I should bccom subjdr ro 'trso*sa con{Ensrion pmvision! ol Sccrion 1700 of rhe L€ttr Code I sltsll. fonhwirh otr{ily enh rho€ pmvisions..
<br />WARNINCT Failun ro wE worhcs' @np€nsrion covctogc i$ unhsful &d shall subiEr & .mploFr lo ainhol l€dlli6 dnd
<br />civ nrei u, 16 orc hun<lai thousd douaB (S100.000). i. addirio. lo rh. con of conp.nslion, dadScs as prcld.n for lhc
<br />S(rio. 1076 ol rhc t-rhn GrL. idrcrc{ ntul nuontt \ rrcs
<br />,",", '1 . 2.r3"- arrrioot,
<br />DF(:I dRATI(IN
<br />I hcEby afllrm u crpcnxl'yorp.rjuryrhar I !n li.cn:\d hdq 0mvnioi or Ch{r$ 9l.ommn. ine wirhsccriotr 7flD)olDirisionl
<br />ol rh. Dusinc$ and Pr.ic$n,nsCodc. !.d mr liccnsc h in tull fore ud ctfccr.
<br />t"I oo1q4..Jt
<br />c()llilBlEualxiNDlNri-&;rlll
<br />i\lucd (Sc. :l(r97. Civ C )
<br />ATPIICAII.DECI.AIAIION
<br />I hft4 atrm und.r Fnaxy or p.rury otu of rhc followiig d(lararionr:
<br />D.mlitior P.rmils-Asbcnos Nori6cltion Fed.Bl RcBlbriors (Tirl.10. Pan6)
<br />-Requtcd
<br />L.llcr of Noiilslion
<br />l^l'lyrhd rhcl.dn0l strh!'onsFlordrngJlh.(.cr.'{*rlm. ( ,nll.crhh ro
<br />'hr nmE\r.
<br />-E/cmrrr rur r rrw ma rhs a!!li(uri,nd narcrhd rhc 0tnrc inrb,nurioi ircotrar I agN ro .ootly wirh xll ciry ond coun.y
<br />ordirtrnccs lndSlalcbpsEblingro hlildin8con(rudbn. n rcDrc$.turives olrhis Ciyand Coumy ro cnrs utl)n Lh.
<br />nhl\r rftnri,)ncd pmlcdy for in\Frrion
<br />ADDlic,nl .r ,\!$l Si{nnlun:
<br />UNDER GROUND
<br />Water-Under floor
<br />Gas-Underlloor
<br />Buildin g Sewer
<br />lnterceptor/ Clarilier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Piping
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Ivlain Drain/Pool Pipino
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Gas Service
<br />Water Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />Hough Plumbing hLols 5\*
<br />Meler Release
<br />FINAL U,7 t/lr(>urg
<br />Notes, Remarks, Etc
<br />Waste & Vent
<br />Area./Storm Drain
<br />Roof Drain
<br />Miscellaneous
<br />Final Gas Test
<br />-l
<br />m€rcnpr hder Sdion-. B &PC forrhis,ca$n,
<br />D.te Oencr
<br />*,", -?.Q-.'D
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