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DATE ID/SIG.GOMMENTS OMs'Build.r D@l@Uon <br />I hcrclr/ !ffim u.d.r p6alt ofFrjury lhar I6 cxdpt fm lhc C6t&!o6 Licd. Li* lor rhc fouowin8 r@on (s 7011., Baind <br />ed Prel6ion Cod.): Any Cily d Couty whrd ..a!id . p@it lo @.8!c( dtd, inPlovc, dmoliln or rcpEir uy slruclurc pritr lo iu <br />iss@cc, also Equic 0!. applicul fo !!.h pmn ro fi|. a iitn.d !tai@@r $ar h. or 5h. h li@Bqd ruwr lo $. prcviritu of th. <br />C@F&rd's Li@?d L.w (Ch+ri 9, C.macinS virn S.<rjo. 7000 of Dvision I of thc Buind ed Pol6ioE Cod.) d rh6r hc d <br />rh. b dcmpt thq?too &d rh. bsi! fa t. .lt.s!d q@pdon Any violarion of scction 703 1.5 by d, appli@r f6 a p.mn lubjd! th. <br />appli@r to 6 civil p.mlry ol no( norc the fivc h6rlr.d &lls (1500) <br />_1, a ownc! of thc prop.ny, or hy nploy.6 wi6 wag.t a thct solc comp.ntation, will do dE wort ed th. structdc tr nol inr.nd.d <br />or ottcrld fq s6l. ( S.c ,0.s. Duins d ProfBions Cod. Tn. Contud'3 Lim. Lsw dG nor lpply b 6 oM.r of rh. prcp.riy <br />*ho buil& orimprovB thtun, d qho dG such wsl niftclf or hcEclf s rhroush his tr hd own .mploy6, provi&d rha ru.h <br />improy.hars e. nolinr.nd.d or ofldcd forsol..ll hovw6, thc buildin8 or improvcmcrr t iold wnhin on.,.a ofcohplcrion, rh. <br />Ownn-Buildd f,ill hav. th. burdm of provin8 that h. or sh. nol build or improvc for the purposc ofelcl <br />_1, a oM.rof thc prcpcny, e aclurivcly @nElcrin8 widr liorcd @n|r'.ro to coBrrud ln. prcj.d ( Se 7044, Bsin6! d <br />Prcfdsioi Cod! Ttq C.nn-..lol! Li.@q L.w dc not .pply !o oMa of prcpdty who buildt d imFov6 th@on , d who <br />cothcrs ror such prcj€G wirh d cmmdo(, lico'.d psudr to rh. conE dort Licctuc Las ) <br />_l m dlmpt ud.r sEdo B &PC for $is 160 <br />WORI(ERS COMPENSAI'ION DECLARATION <br />I hRhy .fiim undd pdalty oi pdjury onc of rh. follovin3 d(,ua!ions: <br />-l <br />hsv. d will maint in r C.ni6.d. ot Co.rd ro Sclf.l$w fo work6' cmporadon, s Fovidld f6 by s.crion l7o0 of tlE <br />t$q Cod!, fc thc Ffro.. orth. wck for which Oc pqnir n iiru.d <br />_I hav. dd willmjntain *st6 cmparadd icume. a rcqui,.d by Setio. !700 of thc Lab6 Cod., for $. p.rfollme of lh. <br />vo* fd which lnis paf,n i! i$ucd. My vort6 @mparad@ icura@ @nr dd Dolicy numbcr d.. <br />Poli.v Numbd: Ernir6 <br />(Thjs s.ction nad nor bc compl.r.d if lhc p.mil is for On. hur&cd dollm l$1001 6ls) <br />A^*^*-**i*,,"lh. wdk for wni.h n\h p.mir ii i$uc4 I sh.ll <br />o l.w, olC.liloi!, ed asr@ 6.t ifl <br />l of thc L€btr codc, I shall, lo'1hwiln <br />wo*6 comp.tuatid @vdlsc <br />dollc {S l00,O0O),in addnion to damagB 6 providcd for tn. S.clio 1076 of <br />rhc Labor Cod., inrc.61 ud $tmcy! fc6 <br />UEENE!_C.SUA!Cf93!_p!C!A <br />I hd.!y.fiiB undcrpdalty ofpdjlry rh l e licdlcd !nd', <br />tlc Duind &d Prcf4.i 1i65. ir in full f6c. dd .fccl <br />of th. wolk for which fii! p.mn ii <br />AtlLtcANE!.0&CtA84!!O! <br />Dcrolitio Pcrtiirr-&bsr.. Nodncdio r.dorl &.8!l.tiN (TidG 40, !.n 6) <br />_ R.quird L.tlr ofNo.ifi..tjd <br />absl6 rcmov.l @.ot.ppliebh to di! Fojet <br />abovc morioi.d prcp.ry for iNp6lio <br />, <br />Waste & Vent <br />Water-Underfloor <br />Gas-Underfloor <br />Building Sewer <br />Area/Storm Drain <br />lnterceptor/ Clarifier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Pipeing <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOUSPA <br />P-trap/Drain Line <br />Main Drain/Pool Piping <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Misc <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewer/Cap <br />Back Flow Device <br />Rough Plumbing EX}'It(trL' <br />Final Gas Test I rno <br />Meter Release r EL) <br />SAMC B'43,290, 556, 6 7 <br />FINAL <br />Notes, Remarks, Etc. <br />PLUMBING.INSPECTOR RECORD <br />APPROVALS <br />UNDER GROUND <br />l097,Civ <br />= <br />= <br />i-