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PLUMBING-INSPECTOR RECORD APPROVALS DATE tD/srG.COMMENTS OWNER BUILDER DEt'ARATION I h@ry .ftm u.rk p<ulty of pajury $a I M q69t tle thc Co,n .6oE Lic.e t * for ft. lollowiis l@n (se.7031.5 B$iB! &id Prcadsion Co<h)r Atry Ciry or C!o'{y which '!q!nq r Fmt to @rutucl, rlc. i6Fo1c &noli^ or tr,an !tfilc{lc FbrIo it3 iB@e,.to rcquiB th. !ppli.@t for su.h Fmi lo fiI. ! si8i.d dddr thrt h. or 3tl. i! lkcn.d Fclh to fi. Foviriod! ot rhc ConrEctolr Lic6!.d L.e (Ctaprd 9, Co'm.NinB wirh S*rion 70m of Divhion I of tne B6ine! lrd P,!f.$ionr Codc) or Or rEor shc ii qonpt rlEctom r.d rh. b..L for rh. dl.s.d doprioi. Aiy viol.tioi ofserioi 70t t.J by ey +pltdt b. ! F@n {bjcl! rhc .pplic&r ro r civil po.lty of mt m.c th!. tivc h!.drcd dol!.B (ts00). [1j]. c oue otrrc pmp<ty. or my.mplor6 wih w.E6 s rhct sL 6mp.n*doi. will.!o rh. wst rd rfi. srrucr@ i! oor-Inlqd.d oro,IE d aor rl.(Sr.7044, Blrind ud PrDfdioB Cod.:fhc Cort6crd t Li.6e LlN &6 tul6pply t horrcot &cFop6ty *t!o huil& or tiFo6 rlE6r. dd wlD d.6 lrt @rl hilMlf or h6&lf or thmush hir or td om eplo)6. providcd rhd 36h inp.ovqftd3drDr itrqld.d qoturd 6r slc. tf hoca6. rlr hliHi'E or irflEer i'mld$nninon )aofohplclior', tt Oq!.. Alilb win hlE U. hr&n ofpronng t, ll. or dr di.l @l hdu or iftpros th. poFny for thc plrro$of -1. a oMq of 1fi. FDprly. e dclBiv.ly conrr.lins wirh li.m.d .onl61oE ro oidnEl rtE Fojer (56. 70{4, &'siB 6td Pr!ftsion Cod!: Th. Contradoas Li..m. L.w do6 .ot lpply ro s ownd o f prcpqly who builds or ilnpre!6 thr6n.ed who co Ecrs ror su.h pmj.d5 vith d Conr6cro(!) ltddl,!B@ rorhcco r6cror's LiccBc L.w). z DECT.Af,AIIO! ! h@by altirn undd Fn.ly ofpqjory orc ofth. lollo*hs d.(bBtioE: I havc and will ,nan(aio s Cdincarc olconsr to Sclf,lNurr aor Lvor te s coll]pemirnnr. as pl o\ ided aor by s{rn{ 1700 otlhc libor Codc for rh. ,,oaonnancc oflh. $o'r lor sticn lnc ponn is isu.d _ I h&c 6d will iainlrin work6 .omr.nsat ion iB@n c. I r.qutcd by Sd ion 1700 ollhe txb.r ftid.. aor rh. Ddf.rll@. of lh. wo,k fo. which thie pmnil is isu.d. My work@ conpo3rlion insur.ncc canjd and policy numb.r &l PolicyNurnbd:___nvUtr(l<dit rhd in 'ha pdfotum. or rh. wod( ror whkh dtu Fmir i! is.d. I shlll mr dnploy riy !o&r in .ny 'rmffi$ alo beorc 3ubjel lo lh. mrta'onFtu.lion lM oac.lifomi.. dd.gE rh.r if Llbuld bc.o@ rltid ro thcmrl6' cominstion p@viioE orscdio! 3?00 of th. Lrbor cod.. I sl6ll. fonl*nh omply wirh rho* provirioff . WARNINGT Fsil@ lo cE s!rt6' oftp.Bdion ordrSc ie u.h*tu|. did sfirll subjal s @ploF to aihi.al poetb adciil litr6 up 16 on. hundrcd tho@.d doll6 {J100,000). in sddition lo rh. losr olcomFMlion. &'MU$ !r prolid.n for lh. Sftlion 1076 oflh. L€bor Cod., inrdcl snd. <Jm.y iiS.3t- lV I OECIAAAIIOT I hcr.by aflirn u.dq poallyofpoj'trylllal I dn liccn*l undLr trorision of('h,pl6 9 (c.,nmcn.ins Nnh seclion 7l)00)otDivision l of th€ BNins.nd F oaesionsCode, Md 'nr licc,R is in lu ll lircc dd cfi(r. Li.(rsc( n\i: l ir. (( \tr rlr' Co.tndo.:_ coNs't RUCfloN t,ltNlltNG cEN( l' I hs.by amnn undd Ff,olrr.lpdjuryrhar lhft ii a consnlcrt'n l.ndinr as$ct lorrhc poh!n.r.c olth. \ro.k fitr shic[ rhis psnil is isu.d (Sd..10e7. Cir C.) AITLTCA.NTDECT,:1IAIIIII I lEel,y .mN undc. !. alr, ol psjry on. of the folloNirs dNl0rar ions: D.molnion PcrhiB Asb€sros Notificalion reddal R.AUlariotrs (r'i1.,10, Pe(,) Reqoircd l-ctrd olNorifi cahn Dlyrith lll( irtiid Counry Ciry tud Counry !o .nld upon {E abov. ,ndlion.{ prcpdly fot Arpllcnnr or gorl Signrl!rc:o,,". sJ :1} UNDER GROUND Waste & Vent Water-Under floor Gas-Underfloor Building Sewer Area/Storm Drain lnte r/ Clarifier TOP OUT Waste & Vent Water Pi ping Gas Piping Tub/Shower Test Rou gh Water Heater POOL/SPA P{ra p/Drain Line Main Drain/Pool Pipino Fill Line/Back Flow Pool Heater/Gas Line Miscellaneous Water Service Lawn Sprinkler Sanitary Sewer/Cap Back Flow Device Rough Plumbing Final Gas Test Meter Release FINAL r/z-*hl Gvuq>r-/Notes, Remarks Etc --t o"," rS-3G/7 Roof Drain Gas Service