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PLUMBING-INSPECTOR RECORD
<br />APPROVALS ID/SIG.COMMENTS OWNER AUILDER DELCARATION
<br />I tcrcby afftrm ud.r Fnolry oa Fjlry rhar I m crcnfl lion lhc Contrelm Lier* t * for lhc fouowing @sn (Se.70l l.t
<br />Busincss and Pof.ssioi Codc): Any Cir, or C@ y whicn nqrtca s Fmit lo onsIMl. aho. ihProlq &mli,h..r q)at dy
<br />imcrw.trtrrons iisu.m, dko r.quirs llf q,plhlnl aor such Fhil lo 6hasig&d ilatcft rhll lI or shc t liened'PMuut
<br />ro rhc [ovisions of rtE Co.rero s Lien*n tl* (Clupr.r 9. C6nmmin8 whn Scclion 7m0 of Diviion ] of rhc Busio.sr lrd
<br />Pofesiao.r Codc) o, thtr lE or sh. is .rnpl thsfrom &d th. blsii lbr lhc llkg.d cr.rDlior, An, violari.n of Sdion m3 I J by any
<br />sptli.anr fo. . pcmn subjers rll. lpplic! ro r civil pctulry of mI md $r. fivc hu.dcd dolldr ($r00)
<br />-1.
<br />&. owH ol rlE proFny, or my .mrloFs vilh MEcs ss thcir slc Nml,cnFarion. will do 0r wltt atn {E sturw is mt
<br />inhndcd or ofcrcd for sk (56.7044. ausires ard P,ltcashB Codc Tn. Colmclo e Lt.m Llw &cs ml arPl, lo e oaa of
<br />|hc FoFny who hiild. or i,prcEs rE6r. Dd who d@s Mh e* hios.la or fi.Elf or lhrc!8n his or lEr own cmplort s.
<br />,rovidcd thlt sch in owmits m mr hrcn&d o oficrd for slc. lf, hoeE rt{iung o lm@nsrl !r sld sithinw )Er
<br />ofotrplcrion. rtf, o'rrcr Blildd wil tsr tlr bodcn oapmlina rh.r lE tr dE dil mt hrild d in+sE rhc pDFry lor th, purpo* of
<br />sLJ.
<br />-1.
<br />asowrcrofthe pmFny. sm€&lusiwlyconrerirg *nh Iccised co 6.loE lo consttucl llE pmj..l (SN.7(x4. Brsrcs
<br />drd Fnf:r.ion Codc: The C..r8cbls Liccn!. Law do.s rct apnly ro m ovmr of propcn, wto blild. .r inprcvcs rh.rcon.
<br />lnd who onl@ls aor !!ch pmJccrs wirh ! Co dcto(,Iiaied pusudr ro rh. C.nh.hls Lhrns t w).
<br />lancrcmDt u.d.r s*don ,B &P,C foroa Easn.
<br />Drlq- O*D.r_
<br />UAatrESE.STMEEdIAIIAtr
<br />DECI,/IIAIION
<br />I hcrcby sffirm uder p.nalry ot raiu.y onc of rhc fouowing d6l4alioml
<br />-l
<br />tuvc 6d will minlain r Cc ifratcofcone ro Scll-lNue tor wLc6 dmFnsdion. .s pmvidcd for by Scclior 1700 or lhc
<br />hho. Cod.. lo. 0E pcnor@N of lhe turt fm ,hich |fi. Fmit is irskd.
<br />-l hsvc and sill mi .in *orkc^ .omFBrion insurdmc. sr rcqun d by Scdiotr 3700 of lhc Libo, Code. for th. l).no,mm of
<br />rhc work io, shict lhi\ pddir i1 ilrxL{ M, workm D insuroncc.micr od lolicy nlnbcr e:
<br />-l
<br />.cnify th,r in
<br />'hc
<br />p.rformme of thc sork for *t hhFnnir i! isstrcd.l *hrll nor cmployonypcrsn in tnytunmr
<br />$ as to bccoft \ulr$' ro rhc uorkr* .on{xns.l io. l.wr or Cali romi0. .f,d 08N lhal ill sholld trccom {hjd r. rrE
<br />*0116 compcnsarionrovi\ions orSari.n l7m.tD. ttrbr C.dc.I shall, fonh*ilh ompl, silh rll)c povirions..
<br />W,{INTNGT F.ilurc r. surc lortcn' co mtcnsal ion colcE8c is unhwfu. and sh,ll subjcl e cmplorr lo simi. Fdlid dnd
<br />civil fin.s up lo om hu.drcd lhoussnd doll.G (Sl0O-000). ii rdd ion m lh. cosr or compcnslion, dam8cs !s povidud for
<br />'heS.ction 3076 oflhc L{hor Codc. intrcn lnd ullo,my s fes5/alL appri.nnr: P4ct ovt
<br />UIE}SIII.I:QNIXAEIOAlli(:uaarlor
<br />I hcrcby atftrm undn FBlly of Frlry thlt I ao lkcnsd lidr lolhioi ot Chlpid 9 Co@rcing w n Scdion ?Om) of Division 3
<br />of rhc Bulircss dd Pofcasio.s Codc. ard hy li.ctrs is in tuU forcc {ld cffecr.
<br />?otlt ?
<br />,h,( 5/zt /1<
<br />CONIIT!]CUONIENIUN$]IGEIII
<br />I hcEhy ulfirn undcr lcnanyorpcrjury'h!r rh.E i\ r.o.{o.rk,n Lndnrg iScncy ior thc pcrl'ormnc. orrhc lotk t)r which lhh lErmn ir
<br />is{cd (s(..1097.cr!.c.).
<br />-l
<br />ccnify ihut thc fcdcrrl rcsllarions Elardi.s asrEslos Emvrl dc nor aopli.ftk lo lnis pmj.cl.
<br />_l c.diry rhsr I h,vc r.dd rhh aprlicarion atd st,rrh.t rhc abovc irforrorion i\ co@cl.l.8rc locomplywilh allCilyrnd Counry
<br />odinaNr and sr.rc bvs ELrhg ro blilding h.rc$y aurnoria rcp(s divcs ol rhh Cny and Counly lo cntr uFo ltr
<br />,hovc mnliomd !rcpcny
<br />Appticnnl or &rni SkEluFl
<br />P.mal.. @n. (pdnr):
<br />UNDEH GROUND
<br />Waste & Vent l
<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 Piping
<br />Gas Piping
<br />Roof Drain
<br />Tub/Shower Test
<br />Rouoh Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />lr/ain 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 />Rough Plumbinq \
<br />Final Gas Test b-a-tK,\deir>d6 +)
<br />FINAL
<br />Notes, Remarks, Etc.
<br />DATE
<br />SgtPxal
<br />Back Flow Device
<br />Meler Release
<br />?rr(ct lie<
<br />c,o,^ &o{al)c'-
<br />t n&rl Addls
<br />-
<br />AITIICANI.DICIdSAIION
<br />I hrr.by alttm utrdcr F.ul'y ol'!'crju,, onc ofrhe li,lh*iig d..lrflrn r
<br />Dcanrhion Pcrnrns Astf,sros Norificrrion ltdcEl Rc[Uldions (lillc40. P!n6)
<br />Rcquncd hncr of N{nifi .dhn
<br />/-+4
<br />€/eq/t?
<br />f--
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