|
PLUMBING-INSPECTOR RECORD
<br />DATE tD/stG.oTVNF]R AU!LDER DI]LCARA'I'ION
<br />I hcrcnl,nlir unlcr t^-trJlry ()l Nrjury rhd I nN cxcnfr lhn rh. O)nrNror' l,iccn\. Irq ntrrhc tulbwtrr! rcrsnr (Scc?0.115
<br />Ilr\i'r.\\ x'xl lrrola\\i($ Codo): Ary Clty .r Cntrrrr Rhich rc(tui.c\ r Fnnir t) r. {d.r. rlrcr, imuotr, d.nDli\h ,t rcl'xn Jty
<br />!nr.rur.. Dri)rk, irs issu.o.c. rl\o rcqunr\ rhc rpnlicrnr lbr \urh pernir t, lil. r si! cd cnEtrl rhal h! or shc n li.cf{ PuNlrtrr
<br />nr rhc no!i\i{n,\ of rhc C,nnrn.tr's Li(n\cd ltrs (Chrt'r( 9. Cornrcn.irg (ih Srcri{,h TiXX) ot Dnnn,n :1 oi rhc Rr\i',c$ trnd
<br />rplllcrN li)rr pcnnir \trhj.crs ihc {rfli.ntrrk, r.ivrll]ctrilt!_.1mr nxrcrhln iv. huDdr.d d.llrs l!5{X))
<br />-1,
<br />as owrcr oa tlr pmFny, or ny cnplor6r wilh eaScs s lhe n sh co4.nsdion. sil do th. *orl &d 1lE dtrnm h mt
<br />intcnd.n or offcrc{ tor slc (5€7044. BusiEar Dd P,trfcsiotu Cod.: Thc Conrr.ror's Lit.e LrB do.s mt q,ply h &n o*mr ol
<br />rh.poFi, *ho huikt or inpro$ tlf,En. sn *h doos*he nins.lfor rEelfo.lhrcuBh hh d hs o$ cnPlottc!.
<br />povidd thlt suh imprc'/ftIns e mr ht .!.t d .r ofrcr.d ior nb. lr. tbwE. t tiildins u h+rctm b $B *nhi. om F&
<br />olmrphrior *E Owmr Build.r *i,l hrw tlI hrd.n olFoving $d h. o. shc dn ml hsild or irytut Oc I'orEly for llF p{rpo$ of
<br />-1.
<br />!s owmr ofrfic lmtcrry. @cicluriwlyc.nrricli.g wilh li.cnsd conlacloB lo consmd Oc tmirr {S... ?o4,1. Busms
<br />nd Eol6sion Codcr Th. Cont.ctols Liccrsc La* des mt opply lo & o*oo oa poFny Rho hrilds ot inrDn*r o.r.otr
<br />tr.d who conrEcc lor such proicrl wilntr Conraclo(O lic.ns.rl Nmanl lo tlE Conrmcroi, Ltco$ t!w).
<br />I,T()RI(EIS' COMPENSATION
<br />DECI,ABATON
<br />I ncrcby !fllrm undf pcoa[, ol Frjry onc of lhc fouowins d(lorulions:
<br />I haw dd will minlsi. a Crnificate of CoNnr to Sclflnsurc tm eork6 com!.nslion. as pmtid.n lor by Scrion 37m of thc
<br />tiUr Cnlc, tor lh€ Fromftc of th€ *ort for wtkh lhc pshn h iisd
<br />-l
<br />havu r will mlirrain {rnk.rf..iqxtrvn rcquncd by Srcrion :1700 or rhc Labor Codc, for lhc pc,fotmftc ol
<br />rhc qork for*hichrhn pemi i\ ns.{. My worln$ninsumnccetricra plicynumh.r m:
<br />-l
<br />ccnifr rhor in rhc pcrfor@tuc ofthc work lor vhich lhh Fnnil k isslcd. I ihrll dor cmploynny p.mn ia 8ny hanmt
<br />$ N(' bc.om subjNt ro th. workcr coflrpcnqlion l.ws ofcalilonid. and agn. rh{ ifl should bccom suhjcd ro rrt
<br />wo*dr omn nstion ,mvisions of Ssr ioo l7(D ot rhc Lltni Code. l $"11. fonhwhh ompl, *ith lhoe tovlcionr..
<br />WARNINC Failor. b surc worLcs'comF-nsdion covcrog.6jcl an c'nplorcr k' cnmiul FMti.\ lnd
<br />ci l finca ut io om hundrcd lhouBDd dolhr (Sl I of .onrpcnsalion, darose as tmvid.d for thc
<br />Sccrion 10?6 ot rlE kbor Cod4 inrcren Md
<br />^,.- 1Po/[8
<br />^
<br />I hdchy lffird udcr Fouhy ol ,,.rjury thd I rn liccn*d hdq lmvnioi of co,nnrncin-! wirh Scclion 7u0o).fDivision l
<br />of lhe Blsiros s.d Pmf*sions Codc, rnd m, li.cnsc k in 6rll fore and cfier /r ,l5b
<br />C '35 c'v n.6n;0 Crlfv
<br />I lrrchy rlltnru.dcr Fmlryolp.rtury rhar rh$c i\ r.on(rudn,tr kndinB r8c..y lnr rhc PcrfonE rc ofrhc work for shich rhn Jl rnlir t
<br />is\u.d lsc. lU)?. Cir C )
<br />A3&II:ANI.T[EI.AEAI&!
<br />I he.by rllim undcr !.nnlr, ol Frjuryor olrhc f.lheirg dcclnr.rions:
<br />Dcnditiotr Pc nit+Ashcsr$ Norificlrioo F.d.rrl R+xlirion( (Tirlc 40. Put6)
<br />-RcqutL\l
<br />t.ncr.l Noriric!rim
<br />-l
<br />.crlify rhll rhc rcd.nl egolarions rcSudnrB astEslos rcmvlt !e nol spnli.rbL io thk Poj.cl
<br />-l
<br />ccnifyrhnr I hNc rcad rtir upplicarion 0rd sr v. inlomtion is corer.l.gre roomplywnh 0ll CilyandCounly
<br />oftlinakcs and Slltc L.ws Ehrii8 El,e*ntarivcs oa rhis Ciry and Counl, lo c,lcr uNn fic
<br />lbovc ftnrioBn pn,Fny fo.
<br />,\t,plirxnl or ,\,r.nl Six. ltr
<br />_a &Plto
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under Iloor
<br />Buildinq Sewer
<br />Area,/Storm Drain
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Pipino
<br />Gas Pipinq
<br />Roof Drain
<br />Tub/Shower Test
<br />Bouoh Water Heater
<br />POOL/SPA
<br />P{rap/Drain Line
<br />Ivlain Drain/Pool Pipino
<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 />Rouqh Plumbinq
<br />Final Gas Test
<br />I
<br />FINAL a 4Wrg 7,it*v*- /w
<br />Notes Remarks Etc.
<br />APPROVALS COMMENTS
<br />Gas-Underlloor
<br />Meter Release
<br />-l
<br />omcxcmpt undcr S$rion-, B. & P C forlhh rcamn
<br />tet€_ _ ()ener
<br />krdcls Addisi:
<br />-
<br />Prmn.r mnc(prin0.
|