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PLUMBING.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATloN
<br />I ncrchy lurn un{lcr pcnllryin F.jD.y rh,r I rm crcmpr ft'n rh. C(dr ttrf l-i.cnsc Ltrw lhr rhc f.llosirs rclvr (Scc.?r}ll5
<br />Btrsi'ic\\ r Pn,f.$n'r Cdlu): A.y Ciry or (i)utrty trhrh rqrircs r lcnnir to .on(rud- rlr{. impn,rc. dconni\h or tPii ny
<br />stncturc. prior tu ns hsurtrcc- rko rcauncs thc lt/icrnl lhrsuch pcrnrir l(' filc r \isncd nakmnr rhd h.or shc s liccntd Punuint
<br />k, rh. nn,vkion\ of rhc Contacttr\ Li.cn*d lrw (Chdfl$ 9, ConnncftinS wirh S.clion ?O(x) o, Diriri,,n I ofrh. Bu\nt.s! 0nd
<br />Pmi.ssionr Codc) or tl! hcorshci\.x.trrpllh.lcnoDrndlhcbssi!iqlhcrllcscd.rcUnnr.Anyvi'nnhtrorsccrion70ll56ylny
<br />+r,li., ,nr r Fnnir iubjcchrh. Uplicrnt h a.ivilpcn,lrlorn.r mdrcihrn livc hundrcndoll.rs (S5{x))
<br />-1.
<br />!s o$aE of rtE I'opcliy. or ny.qrhrcs wirh e&g* es rhcn sk.onilEMi6n. wiu.b 0E smt ond llr slnr{E ir ml
<br />inrdxld m off.Ed lor sle {Se.7044, Bu.ix$ dd Proleisios Codc fhe Cnntraclor's Licnsc l,q does mI .orly ro d owM of
<br />lh. pmFny who builds c i"pmEs tlEmtr ad vlD &'cs sct wrt( himlf or hcelf 6, $Dugh ik d hcr own e mployss.
<br />poviLd rhlr ,kh inprow@nis e er hrad€d orofrotd for sb. !r. bwB, tlE hiHir8 or iqiMmnl ir sh *ilhin onc
<br />'Esofaq)lcrhr thcOwmr Blikld witl har llt tiE&n ofp,lving ttd tEo. slEdil ml hriu in{mw rtE prctEly atrtlE rrlllDsof
<br />-1,
<br />N oqrer of fic poptny. M cxctusilcl, .onrBcrilg wirh li..r*d commtos lo cooslrucl lh. Imjd (Se. 7Oa4, Bunrcss
<br />ard ProfRsbn Codc: Thc Conrrctor's Licensc tiw d6 mr nnply lo aa own( of prop.ay who builds or ir|,roEs lhcrcon.
<br />lnd *ho co'nr.rs fd iuch lfbirts wnh r ConlEcro(s) lkcn*d pEunr to rtu ConrEcrols Liccn* Lr*).
<br />I so crc,npr und.r Ssrio.- B & P.C. ior lhk lcannr
<br />IOBtrE85:.!I}!IEE!!AION
<br />DECIAXAIJUT
<br />I hftcby dtlirmundc. p.dJryorpcrjuryonc olrhc followine delnrarions
<br />-l
<br />h0vc akl willnuirrairr Ccrr iaric of Consnr t, Scll lnsu,e nr workcA .o.Ucns,rion,0s tovidcd lor hySNlionl?(x)oflhe
<br />l]bor Odq lnr rh. ,,. onmrcc ol rhc *ork for whth rhc D.nnil i\ issucd
<br />_l huvc a.d Bill minrdn soikcrs con]Pc$arinn insuronc., as rcquncd by Scclion 3?0() of lhc Libor C.dc, for lhc p.rfor.uc. oa
<br />rh. hrk lor whi.h rht pcmir ii isn&n. My so*ds' .oEp.osatio. insurry cffiicr ed poli.y nlmb.r @:
<br />l1) i.t Nun,hlr
<br />-ljDir.!
<br />-l
<br />eniry $ar in lnc lErforme of thc wo for vhich lhis Pcrhil h i!$.il I .h"U mr cmploy ady pcm. in lny @ftr
<br />s N ro hdom slbirr ro rlr sort6 onp.rslion lasr .i C.tifomi{ and .Sm lhd if I sholld heoft sub}d to rrE
<br />*odcn .orrocBaioo proririons of Selioo 3700 ol ttu t k r Cod.. I snrll lonhv n oryly qilh lh.$ novhioor..
<br />WARNING l-oilurc lo wurc wo.kcis' comFnsari.n cndorcr l. cimi',rl p. lrr\ rnd
<br />idr. drnugcs !s F)vid.d f{tr rhccivil fincs uI lo onc hundrcn lhousand dollar ($
<br />I hcrcby,fllrnurdcr p.trrityoalcrjurylhil I ! lien{n lndcr Dmvnion ofClt{'ro 9lmmnrncirs wirh Sdion ?(m0) ofDivision.l
<br />oa rlE Busincss ,nd Prorc$i(ins codc. md my liccnsc is tu lull nre ul .tlNr
<br />I hcEty ofarn ud6 p.tulry of pcrju.y $rl rlE! is ! @.srEtio.
<br />is.Nd (Se. 309?. Cir. C.).
<br />d8crcy for llt pc omN of lhc ert lot shich lnis Frnil is
<br />ASPIICAILDEII.AAAIION
<br />I h.rcby nninn udcr pcnall, o, Frjur, o.c ol rhc r.ll{,sins delmrionc:
<br />ocrmhion Pcrmits.Ashc os Norific.riofl Fcdcal Rqllalion\ ('Iirlc40, Pd6)
<br />-Rcquircd
<br />lilnof Notificuli'n
<br />_l .cnify $ar UE t dcrd Eguhtioos E8&ding Ebcslos m@Hl m nol o0plicablc lo lhis pFixl.
<br />I .cniay lh{l I havc Etrd lhh apdtal
<br />odiMccs and srdr. kws Elaring ro b!
<br />ion is .or<r. I r!x6 ro enlply wnh .ll cily rnd colnty
<br />rcnro\cnrdivcs of rhi\ ciry Md
<br />lbove n*nrn,tud proFdy lor
<br />Appliuni o. Aa€nl SitBlurc:8
<br />UNDER GBOUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Buildinq Sewer
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Pipinq E]"JP.]id 0/tY 1-z$-tK *.rtbd)
<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 />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 ,,<\
<br />FINAL 1-21-l(X.Wtt)
<br />Notes, Remarks, Etc.\./
<br />Area/Storm Drain
<br />Fill Line/Back Flow
<br />Ic r, \N,nF
<br />tr.n'1.,'\ AJilr$
<br />I
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