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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE tD/stG.COMMENTS OrlNI]R Bt]I I,DER DEI,CARATION
<br />I hercl,y amnn udcr p.nrh,- ,)l li.rjury lhal I Mr cxcnrfl rn, rhc Coika.t,^ l-i.o\c uw r.r rh. n,lhwinr r.rvnr ts.c 7u.ll5
<br />Bu\incss lnd Pdcsion Codc): Any Cil, or (ouory whi.h rcqutcu ncnn ro con{flci. rllcr. i'n8,vc. dcmolish.r rNn y
<br />{fl.rurc. l'turo ir\ i$uncc. al\orcqrtcs lhc llnplicr n, \u(hlf,nnn b fih0 sigtud stilcn{nr rhar hc$ (hci\ liccnscd 0lNnnr
<br />x) rhc fmvi\tun\ of rhc Cont0.rof\ Lirn\cd b$ (Chrfl.. 9. Co'urnci',g sirh S.crtrn 7m0 of Divi\n,. :l i,t rhc Bx\inrs\ lnd
<br />Irrofd\\ion\Codcrnrlhd he orshc hc(cnrpl Ihcrcliomn.d thc hisis rur rhc allcBcd cx.nui.n AnyviohrhnDlSc.ri{,n70ll.5byrny
<br />rmli.anr nn 3 pd'.n suhjsh rhc applicrnrrr r.ivilp.nrh) ol mr nnncrhrn fivc hu i.cd dolhr t S5u)).
<br />-1,
<br />r\ owrcr oi lnc F'pcny. or my cmployccs virh $ recs !\ rltrn k c.o U.nsrn . qilldll rh. *ork ,nd rhc \r rum a
<br />'Nrimc ld orolTrr.dlnrsrlc(S.{?(l1.l,Br\inc\\xndPrclts\ions(-odql'hcConracroi\l,icenscliwdr$norlpplyr,'nnosncrol'
<br />rhcpmFny trh.huild\ori pm\r\ Ihcmn. rl Nlx) d,rs \u.h Mlrk hint\clf or hrr\.lf or rhfl,ush hi\ or hr owh .mlbFcs.
<br />provnk rh, such imrr{TmN\ {r nn inic ud or ollarcd lar {h ll. h.qc!.r. rh. hoi[]ir8 or inDnrrcft is $ld wirhir otrc ,quof( {kri'n.rhcO$ncrtluill.rtrillhnvcrhchurdcnrfproviqrh hc .r shc dil mt huik, or irlrorc rtr pn)!.nr lor rlt nurF}*.r
<br />*1. as ow.o otrh. popcny. mcxclusilclr.o.t0criiB eirh liccn*d conrncro^ ro snsrdcr rlrc lmjd (Scc 7044, Blsitu$
<br />a r PdtasbnCodc: Ttc Conltrtols Liccnsc Llw dBs rer dptlr ro olnrrfrmpcnywh. bnildr or impbvc! rhcr.on.and who cont{cls for su.h pmje$ wilh r Co.li,conr) liccn$d purla 16 rhc C.nr.d.toas LieiE Lr,)
<br />-l
<br />!m cxcnrfl undcr Scdion-. B. & P C r(, rhh rMson
<br />TOf,f,IIf.CAMIIISAIIAN
<br />DDI;!$A.IION
<br />I hcEby afirn undc, pcnnlry ol pqjury ok ofrhc tul,owinB dsldorions:
<br />l hrve 3d {ill nEinluir e Ccrl iarcole of Consnt losclilnsurc n, qorlcrlcotrf.ns nnr. ds ttr vidcd forbyslr'ionlT0Oofrhc
<br />t{hor Cdc. forltc pcrLrnEncc of lhc !or* for which th. fcnnir i\ issu.d.
<br />_l h!rc .nd will mainiain worlrcs comF.srioi iBulMc. $ 'rq!i&{ by Sfttion 1700 oa rhc kbor Co<tc.lorthc l'erf()lrr@c of
<br />lhc vod( for wnich ln! pcmjl is ia €d My sorkfs coq)cnerior i.sur,e @h, nnd oolhy Nmh6 d:
<br />-l
<br />ccnifr rhlr in ll* r.rformkc oflh. *ort for which$k p.rmn k issu.d,l sholl nol cmploy lny p.Non itr ony m.nrct
<br />s *tob..omslbiurorhch 6 onpcnsdioi laws of Calitonio, and urrcc rh ilI sholld tccom subjcd lorh.
<br />workcr( enpcngl ion peviri,,nr of S*rion ]TOO o, rlE L{t{. clnc, I shlll. forlh*irh coq,ly vith thos rmvhions..
<br />WARNINC: Flilurc lo surc workcs .onr.ns ion orcmCc is unhwtul. &nd shell subir' !n mplor.r ro cimiMl JrMhis dd
<br />thousand dollus ($lm.00o), in rddirion to rhc cosr ofcompcnsarion. damgcs as lovidcd lor rhc
<br />Ihcrct'ynrfi n undcr pcn0lrr oiterjury lh l ofChlllcr 9 (mmmncine wilh Sdio, ?fiD) ofDivnion 3
<br />!f lhc tsosids lnd Pmfssions Coilc. dt ny lt.B ir in aull t6re 8n ctf&t
<br />( (rNs'rtllt( - o\ t_titiDtN(;,\llIj\cr
<br />I hcrcb, dlirm!ndc!IEnihrofterjurylhlltherchnconslfl.rion tnditrB08cncy for
<br />'h. Frform0ncc oflhc"ork for whjch rht Frmil is
<br />issucd(sN 3u97. civ. c.)
<br />AITUIANLDE(LASAUAN
<br />I My alin ututr F.alr, of F.jury otu of rh. nnbwins dehrnrio.s
<br />Dcmlirion Pennih-Ashcstos Norificelion Fcdcrrl Rcguldions (Tnh 40, Pnd6)
<br />_Rrquircd lrncr of Notifi clrion
<br />-l
<br />ccnifrrhol ric lcd$al rcaulat io tr s Etnrdi rE 0 shc<o r rc scrlarc not rplli.abk ro rhh pn,ijcr.
<br />-lccdifytl
<br />lhrvcr.adrhhappli.srionrkl{trrcrhrrrhcak,rcinlonn ion i\cotrccr l{C(rhconrplywirhrllCirytrndCounr,
<br />orditun.c( r Srrrcli*\ ruhtngt, hu
<br />aholr nf,flliorcd pn)pcny for
<br />aurhlnx rcI'c\enllrivcs of t
<br />::""iliil;{*
<br />UNDER GHOUND
<br />Waste & Vent qlttlttl ifintot)
<br />Water-Under f loor t u I
<br />Gas-Underfloor
<br />Building Sewer
<br />Area,/Storm Drain
<br />lnterceptor/ Clarif ier
<br />Waste & Vent
<br />Water Pi prng
<br />Gas Pipinq
<br />Rool Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Main Drain/Pool Pipinq
<br />Fill Line/Back Flow
<br />Gas Service
<br />Water Service
<br />Lawn Sprinkler
<br />$anitary Sewer/Cap
<br />Back Flow Device
<br />Rough Plumbing
<br />Final Gas Test
<br />Meter Release 44,
<br />FINAL zh lut rtux VgAt^)
<br />RemarksNotes , Etc.rrT UI
<br />TOP OUT
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br /><a_
<br />L.ndcir Addr.is: _
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