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APPROVALS ID/SIG.COMMENTS OWNFJR BUILDER DELCARATIoN <br />I hcrhy Jrfim urdcr !.nrlry ('i nclurt thd I am .r.'n riom Ihc C.ntu b^ l-ircn\c ljr ntr lhc foll{,wiru, ic!{'n (SN.'loll 5 . <br />Busircs ,[l Pr.f.sn,n Gxl.) Any Cir, or Colnry *hich rcquncs I ,l.nr[ ro consrd.r. trlrs. nntbvc. dcrn)lish or rcldn my .d .turc. |nir lo ils n\u!tr.c. aho rcquncs rhc ippli.rnr tur luch pcnrir b lilc a \isncd lrlrcmnr thot hc or shc n li(cnscd nuru,'nr - <br />llr rhc prori\n,h .r rh. Coiirr.tu \ l-iccds.l L$, (Cnlprcr 9, (nnnrncnrs snh Sc.rio. 70m of Dirisi.n I oi rhc Bulncs .d,i 'Pmnssi(,ns dnlc ) .r rhar hcor\h. i\ci.Epr rh.rcaroarrnd lhctxsn nn rhedlcScd cxcnrption. Anyvnrh(n ofSc.(hn7011.5$y,try <br />npplicrd lnr nFanir \uhi..r\rrr rrfli.ad nr rcivilDcnnlryofnol nnrclhu fivc hutulrcd dollrs iSsL$). <br />-1, <br />ai amr ofrlE tmtcny. or m, cmploles wnh w.Bd.s rlEir sL onFnsrior wil.lo ilE wort( a,n ft nrud@ i! br <br />inrcnd.d or offdcd for slc (Se.7044. BNircss dd Protu.iioB Cod.: The Contr.dn's Li.6s. lje &,cs not apply lo d owB of <br />th. potrny wtb hildr o, iqroq rhc€n. .rd {lE dG ruch mrt hirelf or lEmtf 6, lhEug} hi! q l*r om €q,lorer. <br />p.6vidcd rtat such nlpmw.rs N ml ilicr.Ld d ofl.rd fd sL. li how@. r hrildlry d itrIrMffit is sh witnir om Fd <br />ofoiplcliotr tE Owmr Builde, wiu luw tlE hrnhn of|'sving $d lE or sh. dn d build or inprDw fi. Fnpsry for rlE l{rFe.f <br />-1. <br />0s owncr of th. I,op.ny, am gcllriwly coi'a.rin8 wirh li.cnscd conrmroF ro .onstruc! r,E [mj.d (S(. 70aa. Bunmss <br />ad hofesshn Code Thc Conlrrclor's Licc.r trw doci nor anply to 6 osncr of rroFny who buitds or iry)Dlcs ttcrmn.od who onmcrs for such pmlccts qilh a ConrRlo(s) ,icc6s.d ntrnu, to rhc Conra.ktr s Liccne t e). <br />I ancrdnrpt undc. Scct <br />llirr <br />wotrrt.s' c(rMprNsATIoN <br />IECI.AXAIOd <br />I hcEhy amrn undc penolry of pfjury oft of rhc followins dcchmrhns: <br />-l <br />hrlc el will nbinrain r C.n ifi. rc of Grn*nr lo Sell l nsurc rir \ork.n .ompcn\ar ion. ns poridcd fttr hy Ssrbn .l T(Ir of rhc <br />ttrlitr Codc. for rhc pcrionnlnccorllrc w.rk |or whichlhc!.nnil ( i\\ucd <br />_l havc and will mdinr.in rork n .omp.nsrr ioh inslrrmc, is rcquircd by sar iotr -17(D of lh. L.bor Codc. l'or rhc lcrfo.mNc of <br />thc ao* for which rhk p.rmn is kscd. Nlyworkcs .odpcnsrtion insuBmc c{ricr andnnlicynumbcraE: <br />-l <br />cnilylh in rh. Frrom@ of rhe sorl for which fin p€mir is istud. I shall nor cmploy .ny pcrmn in any ronmr <br />s !s lo hc$m subif,t to llE mrlcl srpcnstion ldwr orcrlifbmiu, and nsNc rhlr il I shorld b..om $bj.rr ro thc <br />hrlcs' olnpctrs.lion lmvisions of Scclio. l70o ol rh. Lrho, Codo I dEll. fonhwnh oryly with thoc pblisinns.. <br />iV,{RNIN(;: Irailurc nr {curc *orkcn'l. nnd shrll subjer an .nDlotrr ro sin nol FMIri\ ond <br />th. cosr oacomp.nsation. &m!cs as pmlidcd for lh.civil fi c\ rf b otrc hundrcd rhousxnd dolla^ <br />sccrn :ll)76 0f rh. Lihtr colc. nn.r.{ <br />l1E!I"13,1r]!)N <br />ol rh.llu\i'f,sr t rrli\\i,u\ (inlu. ud.rr- lic.n\. is ir lillin.c J cll..r <br />c'Of(]+z- <br />o l(o '2ot I <br />I krcby 0mrm undcr tf,Mlly of perJuly lhd I <br />tsucd (Scc.1097. Civ, C.). <br />k a condN.rion bndir! agcEy ror th. F.fo.rrDre ol rr e.t for shich thh IEnn b <br />atrtrclNl!rct aAiIlaN <br />I lxrtylltlmrx ddr p.trrlry ot!.rrrry.nc orrhc nnhsin8 dlrlanniotrs: <br />D.nhlirn,n Pcnir\ Asb\ros Norilicuri{niEdcrrl RcEulntions(Tirlc,!J.Pd6) <br />R.aur.d trI.r of NorifEari.n <br />lhc abovc nrilmEtion tu cotrccl.I aCN ro onpl, wilhallCilyaftl Counly <br />ud h€rcbyuulhorizcE!rcsnroiivcsof fiisCilyudCou ylocnlqulnnrlE <br />UNDER GROUND <br />Waste & Vent <br />Water-Under f loor <br />Building Sewer <br />Area/Storm Drain <br />lnterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Pi ptng <br />Tub/Shower Test <br />Rough Water Heater <br />POOL/SPA <br />f -trap/Drain Line <br />Main Drain/Pool Pipinq <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewer/Cap <br />Back Flow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release <br />FINAL (?ruqls 5t^ <br />Notes, Bemarks Etc. <br />PLUMBING-INSPECTOR RECORD <br />DATE <br />Gas-Underfloor <br />Boof Drain <br />-, orlr ol"rtt, <br />L.ndcls AddE$ <br />o8lrdin8 ,sh.{o\ rcnhvrlrto nor rmli.$hr. rhn lnr..r <br />^,,oiluolntgb-Aqrl <br />-