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APPROVALS DATE tD/stG.COMMENTS
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Building Sewer
<br />Area/Storm Drain
<br />I nterceptor/ Clarifier
<br />Waste & Vent
<br />Water Piping
<br />Gas Piping
<br />Roof Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOL/SPA
<br />P{rap/Drain Line
<br />Ivlain Drain/Pool Pipino
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Gas Service
<br />Water Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Rough Plumbing
<br />Final Gas Test
<br />Meter Release
<br />FINAL ulzqltP I *- 9,0""'1.1t1 ..|,/r(4rt-l
<br />7Notes, Remarks, Etc -I
<br />OWNER BUILDER DELCARATION
<br />I h...by altm und.r ,.@hy oflnjury th.l I m .rc,.tt lDn rhc Orntro.loB Lic.ns. tlw for lh. followi.g r.en (5<.7011.5
<br />Bu.iB! rd Pmfar.ioo Cod.): Any City.r Colnly which rcquiH ! Fftil lo 6.{tuct. ,lla, ihtht d.elirh or E?at ey
<br />fltuctu.. nrior b ns i!s,M, als EqliGr fi. a|,Plicer for sch p.mt ro llL a iigrEd drr.nmr ln6] lE o. rh. i! lie.s.d pumt
<br />to th. pmvi.iionr of tlE Coatlcror'r Lienled Low (Ch.pt.r 9. Cohmrins ,ilh Sftlion 7000 of Diviiion I of llE Buin.ai d.d
<br />Pmfc*ions Cod.) or llEr h. or shc L d.hrt thdeEoi.nd rlE ba!i! for rh. .lLe.d a6p'ion. A.yviohlionofs.dionT0ll.5byany
<br />applica for apmil ob.i*B rh. rprli.anl lo . civil p.@lly.fmr @rc ll . fiw huDdr.d dollars(tt00).
<br />-1,
<br />ar owr of rh. toncny, o. oy.$plorei {M {.9.. d rh.ir sl. corq.rslio., will do th. wort drd llE slocrw i. a,
<br />inr.d.d or otl:Ed fo. eL (S<.?0{4, BusiRss ed PmadsioN Cod.r 'rh. Conhdol! Li(n* Lnw dod mr .'!t,ly io on o*M of
<br />rh. pmp.ny slo ltrild, or i,qftvB $de'r ..d who do6 {ch w* hiorclfor h.elfor llNuSh hir or h.r om c6rl.y.c..
<br />nrovidcd rhsr soch inpmrdr. semr hl. d.dorof6.dfo.ek.l[ t w.E itr hildin! or nq'm1Eft']l is $ld wnhinoc tw
<br />ofcoq)htiol th€ owr B!i6d will harc tlE hord.n ofpmvinS dsr lE or ih. did ml ttild or nirnt 6c lnlIqry tor $. purr.* of
<br />_l,.sownsolrn rmp.ny. d.xchrnrly@ rftrins qith lic.nkd codtur66 ro @trnrucr rh.lFjel (Se. ?M4.8!siB
<br />ad Pnftsio. Cod.: I'h. Contr.ror! Lic.nec Low d6.r.or lpply lo &.eod ofpo0e.ry qho builds or innrev.. ih.ron,
<br />6nd qho .o'nEcr! lor such !Ej(k with 3 Codmto(r) lirn$d ,uNa]tl b rn Conmdoa! Li.cns kw).
<br />-l
<br />ao cxchtr ufld.r 56l I & PC. forrhh r.ison
<br />tLaarlSstcoMt[lsalla!olgtd8Alla!
<br />I h.r.by lmm undrr ,.mhy ofpojury oc ofrhc followiry dcLElioff:
<br />I hivc dftl\'ll rnnr rCrdifi.d.olConscnr()Scllln{kror\rukqs con,tcisar( . xr !()ttrj.(l lar htS.crmnlTol)ol r[c
<br />lihtr(ide.,&ihrperrirnFncco,rhc*orklnrlvh'chrh.nci,nir's'ssu.d
<br />_l hav. d will Dainiain work6 coriD.rootiof, iNr.Be. as Eqlt.d by S.crion l?m olfi. Labor Cod., fo. rn nrfo,mru of
<br />rhc vork aor *hich rhh ,cmir i, iNtd My woilat oqEMrion iN6tu. @itr ati Flicy .unh.r e.l
<br />tintztrmal
<br />Quz<4,*.. 0s
<br />)Ll cc.riry thlr in thc pcrrotum. onh. wo fo. whkh rhE pdit ii irs.d, I shs,l mr .mploy lny Dffin in sny mnM
<br />m .r b iE6@ objftr b rh. Mrtd{ 6mp.mrio. l.wt ofc.lifomio, and asG thlr if I st lld bcmc bicl'oltr
<br />wo.t6' onp.tr*rion tmvtione of S.<1ion l70O oflh. Lstnr Codc I shalt. fonhwnh conply *ith 0r* pDvi.ioN..
<br />lvARNlNOr failurc to scurc cork.B srp.nrs'on co!.6re ( utrl,wtul, ,nd hjd .n ennloy.. to cnm'nalrcMlrFr dnd
<br />civil li.ca un ro o* hlndrd rhousnd &Ua (Sl0{,0o0). o add m. ro th.ofcomn.nsarmn. dnms.r.s nrovdcd f.i rh.
<br />lr Lobor Codc, inlcrc( and d$my r
<br />(
<br />I hecby alIm u.d$ F@hy.f p..jury lt, I m lietred ud.r pmvnhn of ch.pld 9 (dnrJlming eilh Scti,. 7000) of Divi,ion l
<br />ol $. BuriB dd Pmfasioni Codc, ed my liccG ir h tull foE .rd .,L.1.
<br />?>10t114t,
<br />I n6c
<br />cQxsrBucuorl,Ixl)tdc-aclN.cy
<br />I lEehy 0IiirDUndcr r.nohyofpc4uryrhrr rhdr is. c.nntu.hn hnnmS ae.xy lorihe p..fomanc ollh.v'on( nn *hrch lhis pcmr s
<br />Rsu.d(S(.1097. Cn. C ).
<br />ATII.ICAII.DTCIdSAIIOB
<br />I h6Et y a,tm undcr n mlry of ncrjury orc ot iE louowits ddlaral ion.l
<br />D.mh ion Pemrirs-Aib.sios Nodnco' ion led.El R.rllarions (l irlc 40, Pen6)
<br />-R.qur.d
<br />L.lt.r of NdifEation
<br />_lc.nifyrh rhefcdernlrcsrhronsresaRin!,sh.{osrcn$vilire.or.nrlicohlerorhispmjd
<br />Vl ."nify rh"t I h.ft ."d rh, applic.rion .id dr6t..horc rnli,nntuon F cod.cr lilr.e
<br />ord'mnc.s rnd Stsrr La*srtlar'ry roblildrnt cond and Counly to m!6 upon
<br />atovc mntn'n d pmp.ny ior
<br />t{
<br />arn h.rcby lurhnir. repr...d,!v.s o
<br />/{ry
<br />PLUMBING.INSPECTOR RECORD
<br />TOP OUT
<br />Fill Line/Back Flow
<br />Back Flow Device
<br />Lend.r's Ad&r$'-
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