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PLUMBING.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWN tJR II('II-DE|r DILCARAl'ION
<br />I h$cby rt,rnDnd$ Fnrlly ofpcrjuy rhd I nm cxcnll tiorn rhc (, rrc|{,r l-i.cn\c lis fi,rrhc rolk,snrg rcNo0 (so.7i).115
<br />lrusin$\ rtrd Prftsrtnr Cqic) Any Cii, or Counrt shich 'cqut.\ x !.ri n h ..inru.r, .lrs. inltrovc. dcnnlhh rn.n ani
<br />nodurc. nrtn ro i( is\udRr. il\. rqun \Ihc dlpli.mr fn {kh ncinrt ki illc n si8ncd nnlcnr thir hcor shc h lic.n\.d lur\urnr
<br />xi rhc F)visiuN oflhc Conrn h s !,iccnscd Lrw lcharrcr'J. Cornrcncins silh Scrrioo ?(x)O of Dirisn r ofdc auriN\saDd
<br />Ptrnc$ioN C.dc) or rhal hcor\hc i\cxcmrlrhcrrro'.nnd rhcbu\i\ in rhcnllclcil.xcnlPl.tr. Anyvnn nnlofSc.li'nro.rl Sbyrny
<br />+tlicrnr ntr, pcmir rubjc.r\rhc rllplunr b..rvilpcnnlr, otnor nnrcthrtr fivc hutrdrcddoll!6(S51n)
<br />-1.
<br />s owrcr of thc l,oFn!. or ny crqloles wirh *agcs &. rlEn $b onocNrion. will do rh mr* {n IlI s1nllm i! ml
<br />inlcd.d d o,Icrcd for sk (Se.704.a. Burimss nd Ror6sio.. C6dc: Th. C.nrracrols Liens Llw does mr qrl,ly ro M o*nc. ol
<br />Itc pDrEny who buil& or i'r9ots thcmlr sld who d@stuh b hidi.lrot hcncllor lhmu8h hi. or her owncmployccs,
<br />lmvid.d rhd such impbvwlns e mr inrefth c oltcNd for sh.ll llowcM. rhc t{iriing o. inq!*cni i. sld wilhin on. Jt,
<br />ot@r{lctbn, lhc O*tur Buille sil hlr ilE trrdan of loving 0El lE or slE dn d hiin or inproE $. I,DIEly tu rh. pttPo* 6l
<br />l. ns ownc ofrhe popcny. amcxclusiv.lyconlroclinB wirh liccnsd conlmro^ ro con$rud rhc pojccr (se. Iv4. B6incss
<br />ad Aoltsion Codc: Th. Conx&r6r'r Liccn!. l-ls d@r nol ,pDly 16 u own.r ol oropcrty wio bu ilds or ihpolcs lhercon.
<br />and wno .ooh.k lor sucn Foj.(s wirh !Conttrlo(,lk n€dpulMnrrorhcC! .acrrr\ t,kltr* L1w).
<br />-l
<br />m cxcnpl ud.r Scc on-, B. & P.C. for rhis Msn.
<br />IAATEBS:TQIITENIA.IION
<br />DECIAAAIq]I
<br />I ncrchy afiirm undcr p.Mlly of psjury oft oflhc followins dkladrions:
<br />-l
<br />h!!. ,d eill mlnloin . Ccnifrlrc otcoB.r ro Sctf-lnrG lo e.ts .oDpcns.lion. ss F.vi(H for by Seio. l7m of rhc
<br />Labor Codc. for lh. pcfo,mk of tlE ert for ehich lhc pqmi b isnd.
<br />I hrvc lnd will nainrrin *ork.rs. .onNnsdbn nr suilEc. .! ftquird by Seliotr 3700 ol lht Labor Codc, for lne Frfo.m.nc. oi
<br />ompcnsorion insurscc cuicr e'd Poli.y numh.r @:Frnir is issu.d. Mywortc 'lll 't (
<br />c (./.&
<br />-l
<br />ccnify lnal in th. p.rfor@mc oftlrc uork aor wttt lhis,,crnir is hru.{.1 shall nor.nploy o.y Ftron in any mnm
<br />$ * ro bcsft subirr !o the w.,*6s .omr.nsrrion laws ofcdifomh. d.88lhll if I rh.uld b.!oc subrc.r roilE
<br />uort.rs' comp.n$lion povnions of SNtion 3700 of lle L{t r dc. I shlll fonh*irh onrply wnh lhos provisions
<br />WARNINO: Failurc ro scurc workcB c6np.n$rhn mvcrrg. h unh*tul. ald shall subjcct ofl cmplott. ro cinhal Imllhs md
<br />civil fincs !p ro orc h!.n,.d rhousrnd dolh6 (510o.m0), in oddirion l. rh..osl ofc.n{rcn$lion. d!tus.s a trcvidcd t r $.
<br />Sccrn,n ]076 6f thc kh.r C.de. inr.bs and ano.mv\ leseLC.
<br />I hcrcby llftrn und.r p.n.lt, ol p.+ry rhs| t am lieicd uidq piiirioo olclupk 9 (onmEinS wnh Ssdion 7000) of Divisioo l
<br />of lhc 8u.ims a.d Pofc$ions Cod.. and ny li..ns b ir tu[ r.r( &d eft cr.
<br />b I urt /rr
<br />,n, a-C.loe ,-n",*lo.a/4r-
<br />IONiIA]JIIIONIINDIN(;J(iE CI
<br />IhcEby.lhnnundd ttnnlryofrrjurythor lhcrc is!srslruciion lcndinsa8cmy lorrhc pcra.rirun.{ ofthcwo forrhichlhi\ pcn.ir n
<br />i\sEd (Sc. .1097, Cir. C )
<br />EXTIICANLDECIAIAIIO!
<br />I lurby dllnnu.ddr lxtrilry ol pcrjm) oN oflhc lolhwnrs dcchrrrions:
<br />D.nrlirn,n P.rnrn\ Ash.{os Nouli..rion ItdcralRcful.rions (1irlc.l0, Pan6)
<br />Rcqtrft d Lcncr of Norilic.tiotr
<br />-l
<br />ccniiynd rhc lcdcrrlrcErl nnF(Eddii!ffhlno\rcn,rilrr.trorrPfli.{blct,rhi\Pr('lccl
<br />Zt nnntn tIhNre tlhhrpfli.rriur kl{rrcrhilrhc ahovc irn.nnainn i\cotrc.r Iagrmn,conlplt*dhlll(iryrndCounry
<br />ordim^-cs and Sl,r tiws EI.ri.B to bu ildi ofrhh City rnd Counly ro cnlcr urrn lhc
<br />rh,vc n* i,nL{l |n)|rr'rJ,1,tr
<br />Appliconl or Aae.l SlgMlln:1.c./r
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under lloor
<br />Gas-Underfloor
<br />Building Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<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-trap/Drain Line
<br />Main Drain/Pool Pipino
<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 />Rough Plumbing 1/Rl,t 4b 81
<br />Final Gas Test
<br />Meter Release
<br />la/q/ts 5\9s
<br />Notes, Remarks, Etc
<br />Pool Heater/Gas Line
<br />FINAL
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