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PLUMBING.INSPECTOR RECORD
<br />APPROVALS ID/SIG.COMMENTS OWNEI BUII,DEI DEt,C RAfl ON
<br />I lr6by trm und6 poBlry of Frjury llut I m.r.npl tlE llE Contocton Liss Lr{ for the toUowing E&hn (Sa.mll.s
<br />Blliics ad Prof.sior C.d.): Any Cily or County which rcquiEi . p6oir to @inrud, dl6. itrpolq d.tul&h ot Erlair uy
<br />shErE. Irnr b irs hsim. elso rcaoiEs rh. rypli.or for tuh p4mil lo [L. siSn d sl.lffil lhdl lE or slE b lieDs.d puMl
<br />ro rlE Drivhioni of dE Co.lBrol! Liersd t w (ClIlpId 9. Cotrmfting wirh s.cdon 7000 of Division I of lh. Buiirc$ &d
<br />Prcfcsions Codc) or tlur lE d slE ir ctun$ rhcEion &d rhc bari. lor rhc illc8cd cxcm/ion. A.y liobli,n of scdb. 7031.5 by ony
<br />spplicanr lor a p.nnir $bjds lh4 appli.dl ro ! clvil pco.ll, of not mE thu fiv. hudEd douas (S500),
<br />-t.
<br />8 oercr of dE ForEny, or ny.nlpbr$s wilh Mgls s llf,n sL onPcirdion, will do UE sorl lrd ll* slrErm is mt
<br />i, cri.d or off.rcd for eL (56,7014. Btriiftls &d Elfc$ios Cod.: TIE C.nl.scloli Lie.s tlp &'cs nol !Ppl, ro u o*mr of
<br />rhc poFny *ho hildi or in$res thsEtr ,!d who dc3 sn s* himlf or b.mlf or drcudr hk M h.r own !trployds.
<br />pbvirl€d thd su.n inprDEEtu N mt inrdr.lcd tr ofi.r.d lor sb- lf. tnftq. tlE hiiUing or inFr*Gnl h $ld *i$h on. ,te
<br />6ronpleIi),\ dE Owmr BuilLr sil hlE llE lxd.n oaPllvin8 dEr lE or sl. dA ml boild 6 i|proE !E pEpdly lor lh. PEFE of
<br />-!..sowrcrofrh.
<br />Fo!,cny, dcxcl$ivcl,c.n(acrin! wnh lk.nsd.o.inclos lo.onsl ct rh. poitr (Scc,7044. Busms
<br />a.d Pn,&$bn Codq Thc Cilnlr.clols Licrn$ L.w do.s nol alplyto anoD..r ofPoocny who builds or impmts rhcten.
<br />lnd who snlncrs for so.h iftirti snh r ConhdodO licn$d pluunl lo lhc Co.rrslolr Licc.sc Lrw).
<br />-l
<br />ancrcmfl lndu Sccri.
<br />-
<br />OsE-
<br />EAf,&rN:g0MfldsArl!)!
<br />DICIIIEAIIQ!
<br />I hcrcby amrh !.dcr pcnalry ot p.rjn., orc of thc rollowinB d(lr.lionr:
<br />-l
<br />havca.dwill mai.tain !CcdificrtorCons.nr k,sclf.lnsurc t)r volkss dnnpcnsdn,n, ar tmvidcd for $y Ssrion l7l)0 olrhc
<br />bhor Cdc, lor rhc pnirnDtrce ollhc ,ork lor *hich rhc pc,nlir i\ i\\u.d
<br />-l hrv€ and siu tuinllin *or*.* com,'.ns.lion insuraffic. N Equirn b, S*r i.n lftx) oa rhc L.hor Codc. for ft p€f(ru. or
<br />t\,,tr d
<br />IrlJ n insuratue.eicr ,,i Flicy nun$cr uc
<br />bqCI
<br />l .crrify rh0r in rhc pcraorrome or rh. *ork tor uhth rhi. Frn k hrEd. l rhlll ml c&ploy any pc^o. in mt .Mncr
<br />s &s to t sm subi*t tu thc *Mk re' .onF.sation lrws of Cdifodil. and agN rhal if I grbuld 6..om subhcl to 0r
<br />erkc6' @mpcB.r ion Imvhio.s of SKthtr 1?00 ol rh. Labor Codc. I slbll. rodhwnh comPly Nilh lllo$ t ovirionr .
<br />WARNINCT Frillc ro sm sorkcr omFns,lion sEm8c i. unh*ful, ard rhall iubj.cr e c'q,loy.r to ainiral Fe[iI ud
<br />.srio.. damgcs as Fovidcd tor lhc
<br />I ficrcb, aflirm lodcr pcmlry .f FrJUry 'hal
<br />I am liensn undcr povh Chtrprn 9l.omrcing wilh S(tion ?(xx)) orDivisbn -1
<br />I lEEby.farmund.r F llyofFduryrh,r rlErc ir.oisrcrbi
<br />irsu.d (Se. 1197, Civ. C.).
<br />agrncy for rhc Frformn(c 6f rh. wor* lot which thh Fcrnil is
<br />APPL!CANT NF(:LARATI(IN
<br />I knny,Iirn unlur l,,nihyol pcrjury onc oarhc followin-s dccldarn,ns:
<br />Dcnrnirion Pcrmih A\h.i.s Norific.rion ftdcrnl Rc8ulations (l'irlc.t0, PadO
<br />_R.quncd tlrrm of Noriarcori0n
<br />-l
<br />c.nily rnd rhc lcdcra I rcCu lrr ions Egr.dirg osb.rlos romvdm nor arplkablc lo rhlr Ibj.cr.
<br />-l
<br />cenily rhar I h4. rc rhk ll)plic{l ion lrd st.rc rhd tnc ltnE infomrion ir .otrsl. I
<br />ordi rNr\ D.d Srdd lrss rc
<br />ok,!c mnrt,Bl prepcny ror
<br />Appli.a orAsenl SiEmi
<br />hrchyrurhornc.cpr.\c rr
<br />dec t..omnl, *irh lllC y,iy' courd
<br />:,flffiJr,"
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Burldinq Sewer
<br />Area./Storm Drain
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Pipino
<br />Gas Piping 1-28-tg h-t{'tl
<br />Roof Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />P{rap/Drain Line
<br />Main Drain/Pool Pipinq
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Gas Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Devrce
<br />Rough Plumbing
<br />Final Gas Test
<br />A
<br />FINAL 7-zr1y *,{4:0)
<br />Notes, Remarks, Etc
<br />DATE
<br />POOL/SPA
<br />Water Service
<br />Meter Release
<br />of rhc Burimss 0d Profcsions Codc. and ny lk.osc k in tull ldN un .ficct.
<br />4l I
<br />L.ndcrrNrm:-
<br />F
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