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PLUMBING-INSPECTOR RECORD <br />ID/SIG.APPROVALS DATE <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildin Sewer <br />Area/Storm Drain <br />lnterce orl Clarilier <br />TOP OUT <br />Waste & Vent <br />Water Pi n <br />Gas Pi tn <br />Tub/Shower Test <br />Rou h Water Heater <br />POOL/SPA <br />P{r rain Line <br />Main Drain/Pool Pi I <br />Fill LineiBack Flow <br />Pool Heater/Gas Line <br />Gas Service <br />Water Service <br />Lawn S inkler <br />Sanita Sewer/C <br />Back Flow Device <br />Final Gas Test <br />Meter Release <br />FINAL <br />Notes, Remarks Etc <br />OWNI'R TIUILD!]R DI,JI-(ARAIION <br />I hcnby rlll unJcr r--nalry 0r PcrJury rhd I on c\.nrPr rtun rhc Contrxctr\' I-i.cnse liw ,br ilrc lallowirS rcr('n lsc''7011'5 <br />Bu\nr\s ind Pmlc\\nnr Codc) Any Cily or Counrt $hich tcqutc. r I'. nir h .on(nrr. rlr.r' in[rcrc. dcrmlNh 'r rcnin 'nv <br />$flr.rrtrc. priort, ir\ issu{ncc. ul\o rcqttc\rhc rmlicdnl L! such Fi,rir h tilc ! \isncd n tcntrr lhrl hcdr rhc is li.cnrd Pursunnr <br />r, rhd pnni s ol lhc Conr,.u's Lic.nscd ttr* (Chrld 9. Conrmn'in8 *irh Sccrion 70(xr of t)ivision I ur rhe an\i'r's 8nd <br />Prnision\ Codc)orrhr hcor shc i\crcn{l rhcnlionrnd ihc h i\ r(trrhcollc8cdcitnDti( AtrvviinJrionofsccrio'70:115l'yany <br />rprlicanrroral. nlil njcck rhc 0ltlicrnrl. acirilFnrhrornor nlxc rhun firc hundrcd dolllB(35(x), <br />-1, <br />r\ os .rorrhc |x'tEny, ,n nry .mtl.rcc( wilh$rsc\s\ rhcn$[coarPcnldnnr' willdo lic*orld rh.srn)clBisnor <br />i'n$dsl orudcrcd fo; slt (SN 7o4-{. aurinc$lnd l}orc\\ion\ Codc: Tnc Gn ru.roisLiccn\t ljsdocsnol aPpl,t'ntrosncrof <br />rhc nmpeny sh) toild!or iinln)vcs rhcB)n,:md qh. docs ucn w)rk hnnscllor ltrscltor rhtuugh his or hcr own cnl|lbvccs. <br />pnvidcd rhlr such nnnnn$rni\tuctFi i ctrdct or.llrnd Ior eL ll lr)w.]q rhi hrildinA or iryi.ovcnrnr i\ $ld $ilhin on' ltar <br />;l.ompbrn . rh- Osrqlluilds sillluE rhcbu ctrolPn,vi'gilir hcor\h.did tror hlildor inDn)vc thc Inrl.dv forrh' Pury)$ol <br />I. nsoNncro, rhcpmp.dy. s crclu\irclyc.nL,.rirrS*nnlic.n\cdconrr.ronro.on{tu.rrlEa'm]c.l(S( 7ola, <br />'}usi"csand PDtus\i)n C d. Tnc6nk&kn sr,iccn{c l.!w {nrc\ nor rpllyh owndr.fnr.Pcnvllohuildsori prrrcsrtur'oi. <br />rtrd trho.ontrtlforsuchlroJrdswnhncuhcror(s)licctr*dPrNrnrrorh.Coikr.ttrsLi.cn\cl!u) <br />-l <br />amcrcnpl undr s.ction- B. &P,C. fot lhis taon. <br />WORKr.RS' (:OMPTNSATI(}N <br />DECIdBAtr(N <br />I hcrcby atfirm !nde. r,.o.lry of pcrjury om of ln hllowinB d.clnhrn,nr: <br />-l <br />havc en *ill minlrin ! Cetlificdrc ot C.n$nl ro S.rf'l nsurc tt wotrcN con <br />'cnsdioo. <br />N tmvidcrl {or hv sc'tio! :l?00 6r lhc <br />tlb.r Cdc. forlhc poaormncc oflhc m to. whkh <br />'h. P6mir is issu.d. <br />-l <br />tavc und will minllitr sorlrcr' comp.nsalion ia$,Brcc N Equt d bv Sc.rioo l1o0 of lhc Lab.r Codc for th. pc.frmrcc of <br />rhc work tor whi.h rtk l]crmn is isfl.d. My workcs oipen{rion insuarc cdicr ard policy nuntb.. s.: <br />Poli.y Nutr$.r:-Errircs <br />I ccnifyrhlr inrh. nctronMnccolrhc work ror shichrhtPc.nn is irsucd l shlll nor cmplnvonvPcR'n in tnvm0trrcr <br />$ a\ t, bc.on* {bjcd ro lh. *or*.( coq,cn ionlaw\ofcdliiotniu. nnd usNdhd ifl should b..otrf, sunjccr lorh' <br />{ork6 $flpcnsrion nmlhions olScclion]Tmofrhc Lbor Codc.l dDll. f.nhqirhcomply wirh rhos PolnioN" <br />WAINING Flilur. (, sur lorlicrs c.'hpctrsilion .ovcnsc is xnlawful an'l \hrll blc.t an cmllovcr ro riminal Ftulrics dnd <br />civil fincs ut b on hundrci lhou\aod d.lles t$100-(xD). in nddirion ro lhc co( ofconpcnsllion drtuScs !s pt'liilcd for rhc <br />SNion 3076ollhc Litbr Codc. inlc.c{ ,nd rlr.trcy\fes. <br />Applldnl: <br />LII.:ENIDLI]ONITACI9B <br />DEgI,AEAfION <br />I hcEby trfttrm un{cr ll.nalr, or p.rjury lllll I rn lienen u.d$ tmlishn of Chllls 9 (on@ring wilh Scil i'n lfiI)) of Divisn'n l <br />of lhc Busincs .nd Pmfcsions Codc, and nry liccn* h ii lull forN md efial. <br />n\c Nunh.r: <br />-- <br />COIEIBIJEUOTILEIDINGAGIN.CI <br />I hcEby uftum undcr FMlry olrrjury rhir rhd. n ! onslrucrion lcndin8 agcrv d lhc Frfolm'rt 'rrh' work for qhich <br />'his Fnnir is <br />hqucd (Scc. 3097.Ci!.C.). <br />Lr.rLr'! N!m: <br />t .dcrs Addrcs <br />APPLICANT NE(:LARAT!(TN <br />I h.i:ny nijm lndq p.n,lly oipcrjuryonc.rthc followirS dccludbns: <br />D.,rnnion Pcrflrir\ AslBro{ Norincdio. Frd.rnl Rcru ld ions (Tir lc {o. PM6) <br />Rcquncd llllcrol N.iifi clrhn <br />-l <br />ccniry rh.r lh. fcdcral rcsulariods EStdins !\lf,do\ r.movrl ffc nor utDli.ablc ro lhn PmFr. <br />-lccnilyrlEr <br />I hnvc rcad rhh 0ppliciion nftl sl0rc rhlr rhc rhrld inlonMlion n conr.r ! .Brc lo cotplv wirh all Cn, and cuuntv <br />trdintrac$;id skr. bws Elarins,. huildinS coNrruclio.. ud hcrcbyaurhornc rq,cscnhnls oarhi' Cnv a Counrv io cnrcr ulon ltE <br />nbo\c nrnrioncd n!)l.dy ror ins,Ectn'n Illrro*s. <br />Appll..nl o. AB€tri SlpBluE: <br />COMMENTS <br />Rool Drain <br />Miscellaneous <br />67Xdb tD-..fl/r'//?Rouqh Plumbinq t -t- <br />16)-