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PLUMBING.INSPECTOR RECORD
<br />APPROVALS ID/SIG.COMMENTS OWNET BUILDER DELCAIATION
<br />I h@by llitrn ufldcr pcnalry ot n rjury lh.l I d crcnfl iiom $. CrDradoE Litn* Las for rlE followirS eMn (5&.7011.5
<br />Busimss atd Pof6lkn Cod.): An, City or Colnry shkh rcquiG r Fmn lo onsd.L .16. inprorc. dcmlBh o. EFn sv
<br />slruclurc. I,rbr m irs ilium. !t$ Eqli6s llr apdter tor such F ftil lo filc ! sigmd 9sl.B ln r lE or th. b liccMd poMt
<br />io rlE Fovisions ot rn Conr&rois Lic.ned L.* (Ctaptcr 9. Co.mEinS *ilh Scdion 7000 of Division I of lh. Bnsiftlr .nd
<br />Pmfcssi'ns Codc) orlllfl lE d sn is srctrpl ficrchon rnd ih. basis for lhe alL8.n €rctplion- Any violdion of Sdion 7031.5 b, o,
<br />lppli.a for a lcnul $bj(ls thc cpPli.i m a civil ,c.ally of ml mrc lha. livc hundEd dollds ($5@)
<br />-1,
<br />!\ o*tur of rl[ E.icnt. or ry ctrU,loycc\ *ir h srgcs tr\ rlrn $[ .onrB n\d nrn. wi]l do ihc worl Md rh. (MIU$ s nor
<br />ntrflk]rl .r.f.r.d r'.r srf i S\.- 7(!4. arsnr$ $d Proltxion\ clnlc: t hc G lrnclds l-iccn\c l-dw doc\ or tDnlv b rn ownd of
<br />rhcInipcny *ho hrild! or i$t]nivc\ th.rs,n. tr *hodoc\nichsorkhnn\cllorhcr\clforrhnrllhhisorhcrownc t orcc\.
<br />0nrv dcd thll snch i,n[ncnt rs rrc mr i.rcndcd or olliEJ ktr sL l I ho$Er. rh! S{iklinA or i'r{ovcNrr h {rld *irlri" "nr ttr
<br />ol..tr.ridr, rhc Owns Buiklcruillhi\c rh. burdctrolDovirrg rh:[ ln ornrdilnor t{ildorimpmrc rhc Pn,txtr ldrtu qr,*.1
<br />l. is owncr oi ric pro|Enr. rn cr.tu\ntly (oftacr in8 wirh liccn\sl .ontdnF x, cotrdflcr rhr Pi'JN l Sc( ?Olr. 8trnN$
<br />rn.l PmlssinCodc Thc aonk!.nr'\ l.iccn{ l-dw d,{\ nor rDply b u oq ncr of ln)F y*ho6uild\orinrProvc\rhcrcotr.
<br />und sh..onrfl.kli,r\u.hlrojcctssirhICodnctnG)liccn\c Nsurd n) r hc Coitr'ktr \ LnTn\c lrtr )
<br />-l
<br />m crcno undc, Sedior- B. & P.C. for lhir rcMn
<br />D.r€. owner
<br />WORKrTTS' C(TMPENSATION
<br />DEII.AIAUON
<br />I h.rcby omm undcr pcnulr, ol r.rjury om of thc lblloviry dccle.lirns
<br />t hnvctuiwill m{inti r Ccniftlrc .l C.trscfl h Scll ln\urc aor $otk.s- ..rry.nsd ion r\ fn,!id.d tor hl Secrion:}?00 ofrh.
<br />htior Codc. ror $c NrrornnnEc of Ihc trolk ror whi.h thc Pcnnir i! ilslcd
<br />-lh.vcundtill
<br />Einrtrirr workcs compcnslrion in !rm., n\ rcrluircd by St.r idn r7m ofuhc tjb.r Codc. lu rtE ,.rfonMrcc ol
<br />rhc {ork for*hkh rhirFnnir is i\ud Mytrdrkes .omp.n{rii,n insumrcccrdi.r d polty numh{r dc
<br />9t
<br />zlr zotg lz-31- /8
<br />I{ARNING: Failurc lo sue *ort K conpcnsalion otEsc ic unl,wf!|. and shrll slbjirr D .mploJry lo aidna! FMni.s.
<br />.ivil 6n.s up lo onc hurdEd ltouend dollm (SIOO.OOO). in addilbn to rh. on of.onll!.n$tion. d.nE8.s !s lbvided for th.
<br />S€rion 1076oflh.t tor Codc. jnrctc.r Md atomyt fes.
<br />,,,,,.- 1-b-r( noou*^.
<br />I herby aflirn undc, Fnaht of p.rjury lhd I m liensd undcr ,,mvi{oi of Ch,!r.r 9 (s,lmm ins unh s..riin 7ux)) ofDivision l
<br />of $e Businc* snd PDfc$iors Codc. e my li.cM ii in tull foEc ur' cfisl.B 192=*K
<br />o*, I a -b-t ? -.- .-,.*".,X?
<br />coNsTlltl(:t IoN t.fNt lNc acFNCY
<br />I hcBhy,rfirnundcr Fn.llyolncrjuryrhdr rhcr. is d uon{Dcr6o Lltnirs lrrn.y tr rhc lslormucc otrhc wort fot,hich rhi\ Fmn t
<br />issuci tsc. ll)97. Civ C.)
<br />lxtrJcrs Nrm.
<br />lxnJfl\ Ad'l'c-
<br />-
<br />AITLICANLDEII.ATAIIAN
<br />I hdt$y afljm undcr p.n.hy oipcrjury onc otthc folloainS dccls.lnns:
<br />D.nDlition Pcrnn s- Arb.xros Nol i licat ion FedcralRcCuldrionq(Tirlc 40. PIn6)
<br />_Rcq!i6d trkr of Nolificolion
<br />-l
<br />cen ify lhar rhc fcd$al E$l.lions E8ardins sshc{63 ,c@vrl m rct !p!li.sl,lc t rhic Imjct.
<br />\,
<br />AI+nlfy thr I ha\. rcld rhn lnnlraltr oJld {orc rharrhc alnvc iflaomrion is.ml.l.ste loco'ryly $nh 0I Cnvad Cohr,
<br />drdftftes rnd sr.r. tjlsElalup ro hxrld
<br />'nB
<br />.onshd'on, sd hcrcby t!'lrtrlc rcPrcsc ulivcsoflhirCiry".dCounlyroc.tcruponrh.
<br />rlx'lc mnrioncd ,n,p.ay r{tr
<br />Apt,lictrnl or Agenl signrlu Je-
<br />UNDER GROUND
<br />Water-Under Iloor
<br />Gas-Underfloor
<br />Buildinq Sewer
<br />Area,/Storm Drain
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Pipino
<br />Roof Drain
<br />Tub/Shower Test
<br />Rouoh Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />It/ain Drain/Pool Pipinq
<br />Fill Line/Back Flow
<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 />Bough Plumbing
<br />Final Gas Test
<br />Meter Release
<br />FINAL ?a7-6 3),
<br />Notes, Remarks, Etc.
<br />DATE
<br />Waste & Vent
<br />esff s--l .
<br />al4D.t. - I -L- t811
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