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PLUMBING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.OWNER B1'!I,DFJR DEI,CARATION <br />I hrrchy rlli'n trndcr I.nalry r,f lrrjnr rhrr I 'nckchprtomrhcC.itrcktrat-i.cn\ctjrturlhclolbwir8icison(Sc.70315BusnEs\ a, Pnnlssifl C&le) Atry Cny or County which rcquir.s r rcrnrir t, (rnNrucr. alrcr- inrF,vc. d.itlkh 'tr (Jun J , <br />ntucrrrL. prhrro ir\ i$uni.c.ols. r.qri'.r rh.!l)pli.a t,tr surh|.mir ro l]h, \i8ncd st grcnt rhd tEor snc is li..n{d pu uanr <br />t, rhc pnnnn'ns oI rh. Conirr.ttr s l,i.uscd lj* (Ch!flc. 9. C.mnrcncins wiih scrri{'. 70(I} or Drvisrn I ol lhc lrnrir.* 0nd <br />Pofision( Codc) or rhrr lt or sh. i\ ucq)r rhcirfr. Mdrh.hr\ilforrh.lllcecdcrcDprion Anyvi(firionolS.ction?0.11.5$yuny <br />llplicanl lor!Nnnr subjcck rlL applicrnl ro r.ivillcnrlryol trol morcrhrtr livc hund,cd dollarr(S5(rO) <br />l. 6 ovrc. of rhc pFFry. o, my .nplor!.r virh wagcs ai rhcir 5h .omFN.rion. wnl do llE *rt 8rd ltE s.&rm is ht <br />i .rlcd or otrcrcd ftr slc (5€.?044. AlsiM$ od P,DGsionr Cod.: Thc Conra.ioas Liccns tlw dcs nor +ply lo sn owffi of <br />rrE FoFfly {ho hrild!.r inprD6 tlssG ri who dG. eh wl* timsclf or h.rllor dNlgh his o. her osn.,Phrecs. <br />Dovid.d rhat rlch iqroEftnE @ mr intendcd dofrald fo! sb. lf. hoEE( tlE t{iLlin8 q ttpmwtrnl h $ld qithin otu ]ta <br />ofonphrioa rlE OwM Bnildd will taE dr hrha ofp@ting 0El lE or sh. dil mr hiih or inpmw th. loFly fd rhc pulbc of <br />-1. <br />qs owBr ol rh. nslcny, rm .xclusivcly onrEcrins wirh lh.nsd conrEcron ro on{ncr rl* Dmirt (S*, 7044. BuaB$ <br />,.d Prbl6sbn Codc Thc C6mracr6. s Liccok Lrw d6.s .6r {Dpl, ro s own$ of roreny sho blildr or impro*s rheron. <br />3nd lho onrBcrs for sch poitc *i$ a C,nrEclo(, li.cnsd puBurr ro rfic Co.rEcid s Uocnrc Llw). <br />-l <br />on cr.mpl undcr Selio <br />wonl(rts. coMpFrtsafloN <br />DECI,AMIION <br />I hcrcby afllrm lndcr rcmhy of pcrjlry one of lhc follosins dechrrlions: <br />-l <br />hutc ui willtruirt(inaCcnincarcolConscnrro Scll lnsurc lor so,kcrs co'nl)cn\ario.,.i polidcd for hy S.crio.l?(xr ollhc <br />tahor Codc. tur rhc ,nformftc ol thc wod( ior which rhc pcrn is hsucr, <br />_l h!!e lnd willmoinlain workc( ompensalion imln .l?(X) of rhc Lhor Ctdc. lbr rhc Frlomurncc of <br />rhe *ork for whi.h thh pcml h ns*d. M <br />-l..diry <br />rh.r in lhc r.rlormm ofth. wort for whth thh p.n,lt is issucd, I shrll nol cmploylny pcrs,n in any dtuftr <br />so N ro $com slbrrr ro rlr wo*dJ on{Enqrion lr* of Cali,oni& and agrc rhlr af I *h.ull b.r.@ .ub}rl lo llE <br />wo*cc'ompcnsarionpolisionsolSccrion3?0OnfrhcljhtrCodc.l.h!ll.tonhwirhs,nply{ilhrho*tmvisions.. <br />WARNING: Fulurc b wm workc$ cnmrcnsalon orc <br />lo on. lrundrcd rhousund dolhm l$ <br />D[Ct IBAUON <br />I hcEbyafiirmuDilcr FnalryolFrjury rhd I m li.ur und.r ptuvistun olchaf' <br />ot rhc Bn{inc* md Prorc*iohs Cod.. dd f,y li.rns is in Iull rorLr ,}l-rj&., <br />CONSTRTI(]T(TN LENDIN(i A(;IiNCY <br />I hcEhy aftdnudcr Fmltyof pcrjurythlI thcrc h 0 onslrudion lc in8 a8cn.y fnr lhc pcrtomrrcc ofthc{oik rorthichrhilE.nrit h <br />issr.d (sd 1097, Ci!. C.). <br />AISLICANLDECLIAAIPN <br />I lrrrty If, undcr Fnnlr, ol r.rjury.m of rhc folk,rinA d.rhrar'onr: <br />Drnnrirn,n t'rrn,iB A\h.{os Norificntio. Fcdtrrl R.gnlari ,\ (lnlc.l0. Pd6) <br />Rcquircd L.(.r ol Norncarxn <br />-l <br />ccrrily rhlt rhc fcdcrul reBlldions rcsodinB &cbcnos r€m <br />_r ccniri rhor r hrvc rcad rhh apdiorion ro $otly wirh all ciry rnd cou.ry <br />ordinam.s md Stalc LrEs rchli.s lo ilcs ofrhk Cny and Coumrro cnrn uls. fi. <br />nbovc Nnlioncd lnrlE yfnrl <br />Appliconl or Agenl signotum <br />UNDER GROUND <br />Waste & Vent <br />Water-Under lloor <br />Gas-Underfloor <br />Building Sewer <br />lnterceptori Clarilier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rouoh Water Heater <br />POOL/SPA <br />P{rap/Drain Line <br />lr/ain Drain/Pool Pipinq <br />Pool Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewer/Cap <br />Back Flow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release It <br />FINAL llbt4tk.fJ4Fil{)/*'t -., <br />Notes, Remarks, Etc.tt <br />COMMENTS <br />Area/Storm Drain <br />Fill Line/Back Flow <br />'-- -'u <br />*,ag-1 <br />Irid.' e Addr$ <br />f------T------