|
PLUMBING.INSPECTOR RECORD
<br />ID/SIG.COMMENTS
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under f loor
<br />Gas-Underfloor
<br />Building Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarilier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Piping
<br />Roof Drain
<br />Tub/Shower Test
<br />Rouqh Water Heater
<br />POOL/SPA
<br />P{rap/Drain Line
<br />Ivlain 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 A
<br />Rough Plumbing 5'zt'-19 r
<br />Final Gas Test
<br />Meter Release A
<br />FINAL ( -9- lr
<br />Notes Remarks Etc
<br />OWNF]R EUTLDER DELCARATION
<br />I lrcrcby anim undcr pcn.liy of leriury rhrr I a cr.ryi nrn dE Co.r&roB Licecc Lre lor Ue tollowinS rcNn (Sa.?011.5
<br />Bulincss lid Proacssion Cod.)r Ary Ciry o, County whth lcqlaB a Fnil lo .onslNd, !lta, iq,row. dcmlbh or rcp.i, dy
<br />shcrm. Fior ro ils islumc also rcquircs lh. .ppli@t for sucn pcmil lo tile , sised 3rircftni rh,l rE 6r sh. ir licctrsd pursanl ,
<br />ro rhc l,Dlnio6 of rlE Coor6crois Liensd tiw (Cll!pl( 9, ComNEing wilh S.ction ?000 of Dirnhn 3 of lh. Blrincs aod
<br />Prcf.ssions Codc) or thlr lE o. sh. is crcmor rhcrcftom ad rh. b&sis aor rl* slhgcd .rcn rinn. Any violedon of sc.tion ?031.5 6y sy
<br />atiplicanr for ! I,cmit $bj6ll rh. ap?li.a.t io ! .ival pcotry oI .d ruE $o fiv. hundrcd dolld (S5m).
<br />-1.
<br />ri owM of lh. treIsrly. or ny.nployes wnh *08!s !s lhcn $k mmlcn$tiotr wil! do tlE wort ard th {nElm is ml
<br />i cnd'n or ofrcrcd fd $lc (Sd ?044. Blsikss und PreIcssions Codc Thc Co 6.1ofi LiccN t w docs nol q,plt lo an oercr qf
<br />ilE roFny Bho hitts or iqmB ttxdn, dd eh. dds sEh $li hin*lf or nds.lfor lhrcugh hh or hd oM .n{tl6}€..
<br />provAcn rh.l sBh imploEmnts @ ml inrcnd€d orofrcr.n lor sok,lf. hovcEi rhe tr&iin! or inllltuw@or k $ld sithin.n.,ts
<br />ofonphbl! rlE O{rc. Buillr win tuw 0r hnkn of pDviig lid lE s shc di.l ml hoild or idlme dic IiDFny lor dE l qns of
<br />-1.
<br />s owftr .f rhc rep.ny, !n crcluriv.ly .onrdhg *ilh lieBd conlracloE k, onslrcl lh. Drcirl (Se, 7044, Burin.{s
<br />arn EofNio.Codcr Tnc Co rchr's Liocnsc LI{ d@s nol E,:ly lo u own$ or prop.ny vho btril& or imprcvcs thcron-
<br />md vho .onrek for such pm,.ds wirh r C..lftro,ls) lt N.d puBunr ro rh. C.nt!.rols Litns tiw).
<br />I o .rcmd undn S.dio! , B. & P.C. for fin @sn
<br />w(lRKf.{'s coMpf,\lsaTloN
<br />I'ECI.AXAIIT}N
<br />I h.rcbt amrm und.r !.n.lly of rsiury om of thc lollowirE debElions:
<br />-l
<br />nnvc uxl q ill ruinrrin ! Ccnificrrc oi C.n*nr ro Sclt ln\un fu $(rk&f ..t!f,nsrrio., 3s proridcd for hyS.clion.lT(x)orrh.
<br />Uh.r G)dc, ror rh. p.rri)irn0nccollhcuork lbrqhichlhc pcmir is irsucd
<br />-l haE od w ill mointoin workcft cohFnsarion iNurancc. as rcquncd by S.clion 37m of $c tjbor Code. to. thc llcrformN of
<br />lhc work for wnich rhis Fcmir i. nocd. My {0116 mq*"salion inslam .{rir dd Flicy numh.r m:
<br />_! enify thdl in lhc pcrfornEncc ofthc *ork lor which this pcnnit is issucd. I sh0u.or cmlloyony !.Mn in.ny ronncr
<br />$ {s lo iEcom subid ro rhc sorlsl comFnsi.n hwr of Calitodia. ard ag@ rhll if I should he.m subid to rh.
<br />workcr'ompcnsotiotrlrovisionsorSerionl?00otrrrLuhnCodc.lqhJl.lonhwnhamplypithlhospmlnions
<br />WARNING: Fdilurc id scm sort&{ comp.ns n,. covcng. is unl{wful. rd sh0ll subFr an cnDloyr ro dnniotl IEMtis and
<br />cilil li.es ul ro o* hundrcd rholsnd dolltrs ($100.(x)o). in ad.lnnrn k, th. cost ol compcnrarion, dsmgcs N provi,cd fo. lhc
<br />Sc.rion:10?a)ofrhr lf,titrCdlc. imcr.{ rtrd dldiir! \lltolzol*
<br />DECLdta rd
<br />I hcL-hyilltnrundcrptfrlrrolptrjsyrhur I r li.cnkrutuhrfiori\6nolChrllcr9lcon ncncin8 wirhScdion 7{x)()rofDni\im:l
<br />ol rhc BusirEsrnd Pnrcsrnrn\Codc, ud 'ny liccn\c is intulll{r.rrndcltu.r
<br />R (o r zz-
<br />CANIiIf,!!.:IIANIEN!,INIiI!]INCI
<br />I hcrcby n,ltm !frlcr Is.ohrolp.rjuryrh,r rhft i\ a.l,nio.ri,. Lndin! atcmy ntr thc FrlbmEmc oflhc sork ror whi.h rhh lsmir il
<br />issucd (SLr. .1097. Civ. C.)
<br />AIIUCANLDICIdf,AIII}N
<br />I tLnb, nltim undcr F,m[yofpcrjury onc ofthc l'ollowitrs dc.lurrlioN
<br />D.nk irn,n P.imn!Asb.{os Norificrrion f;c{icrrl Rc8uldions (fillc.l0. Plrl6)
<br />Rcqurcd ldlcr oi Noliltilion
<br />-l
<br />ccnny rh.r rhc lcdcdl ,crllario.s rsoilins asta\ror En,val uc mr lpplicablc lo lhis lmj.rt
<br />-l
<br />$dily rhol I hnve rcsd rhis aprlicattun dd srarc rhar rhc !b6w infornDrion is con$I., sCft lo ompl, *irh lll Ciryand C.unry
<br />ordinamcs lnd Sr,'c tjws ELrine ro builditrB consrrucrion. and h.Eby turhorir ,rivcs olrhis Cnr od Counrr ro cnrd !F.lhc
<br />rb(r. trf,nri{,md F)ncny f(tr i'}fc.ri(
<br />,\ppliunl trr A[.nl Siqntrlurr lo
<br />I
<br />MI
<br />APPROVALS DATE
<br />k.,\Ll$,i
<br />r:rDi':,
<br />&
<br />knd.ar AJd'.s
<br />-------T------
<br />I
|