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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Buildin g Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarifier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Piping
<br />Roof Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOUSPA
<br />P{rap/Drain Line
<br />Main Drain/Pool Piping
<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 Plumbing lt-t9 - /g 6M lo
<br />" b- //,1"/P@
<br />Final Gas Test
<br />Meter Release
<br />Y***tFINALAtlbn {uu)
<br />Notes Remarks, Etc
<br />OWNER BUILDER DELCARATION
<br />I h.Elty.,Im undd p.Mlry ol!.rjury rh l m.xcn r frod 0E ConfucroB Licens L,w lor th. f.llowin8 Msn (S6.7011.J
<br />BusiBi .nd Phld.io. Co&): Any Ciry or Connly wnch r.qun* . Fmn ro on.rrocr. ah6, imlmk, .Lmlilh or qat a.y
<br />strocturc prior lo nr im.nc.. dm (quiG lfi. aDplic.nr for Nch ,.mir to lil. a risn d $otffit tlul & or sh. i lic.Nd pulsr"
<br />l. lh. pbririoM of fi. Coflr.cldi Lic.n!.d Lre (Ch!l)r.r 9, Comcaine wnh S.crirf, ?000 of Divi3ior 3 ot lhc Buri.c&e ,nd
<br />Prcf.sio Cod.)orlhd h. orih. ir.x.dpl lhdfmm.d th. hsi! lor thc lucs.d cx.mplion. AryviolsliotrofScclionT0ll.5bya.y
<br />arpli@ f.r! Fdir shjl,r. th€ applicr ro ! .ivil pcmht ol mr me rhai fiv. hu.d,ed d6lld ($500)
<br />-1,
<br />I o{n.r ofrh. nop.fir. or hy .hplorr* w h rylgd as rh.t bL 6mtrierio'! eiu .b th. ub,i ntd dE rruoE t mt
<br />iordd.d o.olrd.d L, sh (5@,7014, BBiIBaid Pmt$ioN Codc Th.Co E.rol!LkryL3w&,6mtrpplyroeowdof
<br />th. poFdy who hiild! or itrpmB ttE6l! rd wl[ &B nEh m& nins.lfor lEs.ltor thmlgn hi3 or lrr osn .mtloy..3.
<br />[ovid.d rhll ch itr!,m@ ! G mr intqd.d or o,&Ed for ek. l[ tnM. rtE huikti@ d in{mcGI k sld wihi. oN F
<br />ofoq,hiol\ lhc Oeft. Brik!. wiu lbt th. h!d.. ofpmving rtld h. or dE dii mr tliB or lmlw dE ,ioFry i,r r& !u{rs of
<br />-1.
<br />s own.r ofrhc pNp.ny, M .rclusivcly onrm.ring wnh k.6.d 6, 6cloF ro oNtfld lh. poid (Sd. 7044, BurhN
<br />ond PoG*ebn Cod.: l h. Conlrclois Lic.m. Law d.$ mr.0plylo..owtur olrmFnywho huilds or imrm!.r $(@
<br />ed wtn @InBds for och porcKwilh6 Cot{eto(9 lic.trEd rll1Mt rorh. ContE.lol. Licc.c tlw}.
<br />-l
<br />am .x.mrt undd Setio, , A. & P.C. tu. thii rcas.
<br />llof,trlag..caMlEllAM!
<br />DEqASAIIO!
<br />I hcby lllim und.. FBlty ofpcjury orc otlh. followi.s d6lat rio@:
<br />_l h.v. and wil! nri.Gin r Ccnifiol. ofcon.. ro s.lf-looE for mrkm omp.nrliM, d pmvi.Ld lor by Sathn 1700 ofth.
<br />Ldor Cod., for lh. pdfo'1lrlm otth. e for whi.h rh. p6nir i4 Ls.d.
<br />_l hav..ndwill mainrsin sorkcr'.omp.nration iNumm.,.s rcquiEd by Sdrion 3?00 ofrlE l}bor Cod., for lh. Frlo@c. ot
<br />lh. mrk for wfiich fiis p.mit i! is.d My world omp.nslion insBmc otris &xl Flky nuht r a.:
<br />Policy Nuob.r:_Ex!
<br />WARNI C: lailuE ro suE so]*t*' coo{Eneri.n
<br />civil n..i !t' ro o.e hundr.d rhousnd dolla$ (S100
<br />S.clion 10?6ofln Lator Cod€, inls.d lnd lnormr.!
<br />is hhetul. .nd .hrll sbl.d .n m!,loFr lo riminol no.lti3 and
<br />iorl dnmg.s as pmrided for th.
<br />I h.Eby alfirn u..h. I'.Mlly ofFdury th.t I s rnnl$.0 . f ('h.nrs I (.onnnen.in! Lvirh SeclNn 71J00) ofDtrrrnn ll
<br />of rh. AGrNss and Pmf€ssionr Code. ' lhylic.nk*
<br />\5-t"tB1
<br />I h.cby.mrm und{ FMlryolF j"rt ttur
<br />'h.E
<br />is a 6[{rudio6
<br />nsu.d (sft 1097,Civ. C )
<br />aE y for lh. !.rfomomc ofrhc aod t r *hich rhh dnn il
<br />AII!rcAILI'IiCLABAIJON
<br />I hcby lIim und.r p€nohyofFrjuryo* otrh.lirlo$ins d.ch6rions'
<br />Demlition Psmits'tuh.sto8 Nolifiqlion ljedc.il Rc-guhtbns nlc40, Pan6)
<br />-Rcq!t.d
<br />L.xcrof Norifi dlion
<br />I cd iry thar rh. f.d.6l Elul.'ions rc8anlin8 rsn (o. r.myal rrc mr aFlli.nl'lc ro thh pmFt
<br />-l
<br />anify th"t I h,v. r..d rhis E Dlicarion tud n.t.li.l thc 0bve infomBrion h cor.cr. l.!rdro conrly{nh allcnyand counry
<br />,,^l'mncec,M sr .l r*i EID
<br />'ne
<br />rcbul.dhd con{rudh,tr tud h.rh! 1!1k,. r.nreqntxrtrGs nl rhN(-rry?nd codnrJ r..nh uFn rh.
<br />,huv.m.dn,tr,rn1,l,'d),c,,n.r"'-x\ n,{_i
<br />Appu(r or {E.n,shnrur: / / \ l\ L\- D'r.TJ
<br />Pcmrlle. n.me (prtnr):
<br />v
<br />I
<br />I cenify lttrt in th. r..aorrurc. otlhc work for $'hich thisrtrnil is isrudl, I shau nol c.nJ)loy a.y p.mn in any oanftr
<br />e a. to b6ft 3ubj6t ro rh. mrin' 6nll.nsri6n lasr 6fcalir6ni,. and rgE rhd if I .h.uld h..om subjd to lh.
<br />w.lk6 6nr.nsri.n pmvrion. ofsdtio. 1700 ofrh. t tbr cod( I JEll, aonhwnh omply wilh lhr* povisiotrc..
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