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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.
<br />UNOER GROUND ,
<br />@>)Waste & Vent tll/u|P e
<br />Water-Under lloor
<br />Gas-Underfloor
<br />Buildinq Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent ilMlr n '4/lolrn^lE\-/
<br />/r*1,r4r/{4)Water Piping rilrt,s r\
<br />Gas Pipinq (J
<br />Roof Drain
<br />-pqc4'2Tub/Shower Test IilY/UTl .q)
<br />Rouqh Water Heater UL
<br />POOL/SPA
<br />P-trap/Drain Line
<br />tt/ain Drain/Pool Pipinq
<br />Fill Line/Back Flow
<br />Miscellaneous
<br />Gas Service
<br />Water Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />arur^A;Rough Plumbinq t>lilo? 7n 21)
<br />Final Gas Test t u
<br />Meter Release
<br />2h)tlelrqfi ,N^r.ArJ
<br />Notes, Remarks, Etc u \ \./'
<br />-s
<br />OTVNER BU II,DT:R DELCAXAI'ION
<br />I h.r.hy rfln uftlcr pcnahy ol p.rjurt rhd I m cr.nrr ln rtu Conlruct,^ l-i.cn\c ti'r tu thc folk,wii! r.&,r (5$70315
<br />BosirEsr . ltolcssion Codc): A.y cn, or County rhich rcquitc\ r Fnnir k' con\inct. alrc,. idtidt. 'lcrmlhh or torrn nnv
<br />slrucrurc. rrir ro ir\ irsun.o. rlso rcquics lhcrpplic"trl tur $ich Fnnir io flc0 \tncd srarcmnr !h,r hcor shc is liccn\dd pf\orrr
<br />ro rhc pn,vilnrs oi rif, Conrracr{tr \ t-iccnr.d bw (Chrtrcr 9. ConnncicinS *irh s..lnnr TuJO .l Divi\iu1l .i thc Businc$ rryl
<br />!ppli.rnr li)r ! prrn,ir subrcch lhc amlicanr t, a ci!il pculry of to frrcrhrn livc l,undrcJ dollr (S5U,
<br />-1.
<br />!\ owmr oa rhc lyo,rny. rr nry cnrrn]ycc\ wirh w!!.\ r\ rhcn {ih comnctrqlion. will do rhc qork uxl !h. ddim k mr
<br />inr.nncJ.rollciL{r.rslctsc7orl.3!\inc<s,ndProfcssi.nsCodc:-IhcA'nta.hn\Li.cnscLardocsnor,lllyrortro$ncro,
<br />rhcpR'I{rr, *ho htrilds or i'nfli,vcs rtrNn. ul uho d€s \uch trr)rk himsclf ot hcrssll or ihrou8h hh or h.. oen cmpbreds.
<br />prolnhd lh0rsu.h impnemnB dc fr imcndcd oroilqcd lnr \!lc ll ho*.vci rht hnildir8 or imrovcmir i1\old wilhir.nc ttr
<br />olRrnpldioD. rh.Owncr Auil(ls willh0vc rhc burtutr of
<br />'l(,viru
<br />rhrt h.orsh.did noi l iklor irl{)mvc lhe Pn,pcn, fitrrlf Pu{n$of
<br />t. x\ rnd ot rh! [oncny. !m cr.hsivcly .ontacrin3 sirh liccned conrrdB tr .oNrd.t thc lllojEr I Stu 7(]U. Aulims
<br />d E!t$sin'clnt l'hcC-oitrctol\l,iccnscLawdoc\n.rapplyiooowncrofProrcny*h.buildsorinfiotc\rher.on.
<br />6nd who cooh!1s for such lmj.cis wirh . Co Blo(s) lic..scd Pusuil to rhc Conkelor "U'^/'
<br />Sslion-, B. & P ottul- t-looc'O t)77--1-
<br />I hcEhy altrrm undcr pctulry of pdjlry om of lh. followinS d(
<br />IhrvcrklNillnui llnrCcnilic{.ufC.n\.nrhSclflnsurcl'or*orkc6 conr$nsirion. N ptrnidcdLrbyS..rionlT(x)ofrhc
<br />l-^ti, Ci{ic,lor rhcrcnonNncc olihc solk f(tr*htrh rhc Jrnnil i\ issEd
<br />-l
<br />hsN and {ill nrininin q o*cn' conrpcrslrn,n i'Funtr$, as rcquncd hy Sccriu .17(n ol thc Llk, Codc. n, rh. ,r nnMrc oi
<br />d{ work tu qhi.h rhis p.nnit i\ nsucd Mt *or[.tf .onD.n\rrion nsunncc crrid rd B,li.r nunrhcr ar.
<br />Policy Numbcr:-ErPitrl
<br />-l
<br />cenify fiar i! lh. performncc of lhc sork ffr which this !.rmir is hsusd. I snll nor .nPloy anv ,.*on i. uo, frmncr
<br />s as lo bcsnE subj.rr ro rh. 8od<6'co.rp.nsalion bqs of Cllifonie ed ,8N th.t il I should h.com biEl lolhc
<br />wortcB' conqrnslion pnvhioN of S.{hn l7m of llE tltor Gdc. t shall. aonhwith str{,ly wnh *Ec pmvbiotrs
<br />WARNINC: Flilurc to s!rc wotk r' comrcnelion covcroEc h unlawtut. ond sh{ll subj.tt an
<br />.i!il lln s up to orc hundrd rhouend doll{s (SI00.0.Jo), in dilion r. rh..on of comp€nsl
<br />C.dc, iotcr.sl Md otloaEy\ fccs.
<br />a,(
<br />I h.rcby,nimr und.r p.mlryolpcijury rh,r I a li.cnwlunrlcrlmvnioaofChrPrs9(.onnrtrcin8!nhS.cri,n7(xx).rl)ivisn'n:l
<br />of thc Busincssand Prcr.$ionsCodc. ord nry liccnsc h tu tulltucdriclisr
<br />COIIIA]JcIIONITIDINCACI'ICI
<br />I hcrcbyrlii, u ncr rcnllrrolp.rJuryIhrl rhcr. hrconslnrlion I ingi8ctrcylhrrhcncrtorenccofrhcworkix{hi.hrhi\F*nnrB
<br />i$ucd (Scc. .1097. Cir C ).
<br />L.nd6 ! Addrds:
<br />A.STLICAILDICITI8AUqN
<br />I tuy aninn undcr pcnah y of pcrjury om ofthc followin8 dcclotllions:
<br />D.@Inion P.i,nirs.Ash.sros Notiliceri.n Fcd$al R.guldlions (Titlc 40. P|n6)
<br />-Rquircd
<br />t rr.r oiNoriferbn
<br />-l
<br />c€nify rtEr rhc H@l Elubrions Egsdin8 esbcslos Emlsl e nol tprltablc lo lhG ,tuirl.
<br />-l
<br />ccnif, rhd I h,vc 40d lhis lpplicolion ard sure th thc lbovc infonnalion i. .omr. I a8@ lo o,r{,lyqnh oll Ciryand c'ounr,
<br />ordinanccs dd srarc L!w\ Eld in8 lo huildins con{rudnD. !d h.rcby
<br />abovc mflbncd loFdy for inspc{lion Ituqbtgj.
<br />Applic.ntorAec Sigmrurc:
<br />P.mitR Dme(prid): X
<br />v ::'.^r7;;;
<br />COMMENTS
<br />Pool Heater/Gas Line
<br />FINAL
<br />-
<br />Conlr.clo.:-.
<br />LrnLlq'. Non'c
<br />-
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