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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE COMMENTS OWNIIR BUII,DER DTI,CAR TION
<br />I hcrchy afinr undcr ll.nally ol pcrirry rha' I m .knDr tmd rhr (i ra.tni Li.ctrE lj{ for rhc Lllo*ins Nvr lse 70ll 5
<br />B \inc$ x l Pmlc\\i,,n Cr .r Any ciry ur county qhi.h rcqunc! . psnr n) con{rucl. alrcr. iBpovc, dcnnnrsh ur eNn u,
<br />sru.rurc. t)rk,to ir\ i$unncc. aho rcqutcs lhc lPpli.llll lnr such Fn.ir b lilc a \isncd sd.'mn' rhd hc o. $c i\ li(cnscd IuFUanr t
<br />x' rhc pn,vi\n,ns or rh. Contrfttr \ Liccn\cd bq (Chrtrro 9. Connncmirs nilh Sccri'n 7(xr, of Dii\ion .l ol lhc Burincs\ 0trd
<br />PnncsbnsCodc)oith,rhcorshciscicnDtlhcrcfro.ndrnch i\ rbrlhcllkscd cxc rrri{,.. Anyvid.rn olsr-^rion70:ll5hrnny
<br />alplic.d lnr.txnnil (ubjlrr lhc apflicanlto acivilpcnahyolml n{rcth6,l\t hu druddolllnl$500)
<br />l. l\ own$ or rlr In,lIny. or y c lk)yc.s wirh wrgc\ h rhcn \,1. co"rrflsrri,'n- *ill do rhc uo' !. drl ih. nurut i\ nur
<br />idcMcd..oll.rcdldsnlc(S(704i-hr\irc$.trdPrci.siotrsCdr:'lhcC.nrracror'\Licn\.bwdocsnoi{plyl.in.sncrol
<br />rh.,n'pcdy *ho bnili\ or i'rymrr\ rhcRm. r,xl rkl drs {rh \ o hin,\.lfnrh$sclro.rhR}uAhhisorhcro$ncmnlt,yc.\.
<br />ofrorlnlori(fl, rhc Owmr Buildu willhrtcrl[ hudcnoffmvirSrhd hLor\hcdi(l tror bui o. n+ro\t rhc nn tr1ly ror rhc N!r$ ol
<br />-1.
<br />.s owtur of rnc ,m,'.ny. rm crchsiecly conroding *irh li.cnrcd .onthdoF ro .onslrud llE pmjccl (Sft. 7044. B!.incs
<br />.rrl Pb&sri6n Codc: Thc Co.kmrols Liccn* ljw der nor apply lo !. owrcr oa proP.ny who tsilds 6i improv.s fio.on.
<br />lnd who onrracrs fd slch pmFrs sirh ! C{nrtulo(s) ltl6cd ,runM o rl* Conhcloas Lic.n$ ta*)
<br />I mcicmDr uds S(ron .B &PC forrhs@$n
<br />]IABf,EETOMIENSAII!}N
<br />DECIAf,S.IION
<br />I hcrcty liiirnu.&r pcnllty o{ pojury oe o{ lh. fouowins d(laali6ni:
<br />-l
<br />hrvc.nd will mint.h. Ccnifrdcofcon* ro S6tf-lnsrc fn krk6 omp.N ion.s povidcn for bySeion 1700 of$c
<br />Lib., C.dc. ftr ,E FrforltEre of thc srt ftr whtt llE I'cmn ir irsd.
<br />-l
<br />havc .nd *ill tuinhin erlcr' coEl.nsriion ins@c. 8 ,equircd by S€liofl 1700 of lhc Lltdr Code , for rlE pdfo,rMc. ol
<br />lh. e.l for which rhi. Foii ir is{.d. My wqt6 ompcns,rion in$lmc .ai.r dn policy nnmb.r t:
<br />-l.cnilyrh
<br />in OE F fordmc oa tlE uork for stth this Frm iF nswd.l shall mrcmploy.nyFMn insrrtrUrcr
<br />$ !s ro b.d,ft sobjrr ro tlx uortos conFnsrio. l,wr or Caliromir. and l8e $ar if I sh.oB tE om $bifl to rlt
<br />sort6 @nFnerion pbvkionr of Sc.lion lT0(r of lh. L4bor Codc. l ddl. fodh*nh @aPly qith rhd* previsions..
<br />lV/\nMNGr lrliturc h sw sorkcG' ..mpcnsalbn olcm8c is unlawtuL and shrll subjd .n cmplor.r lo aiminal pcMhics and
<br />civil finci !p ro onc hundr.d rhousand dolles (SlU0,00o), h addiliotr lo lhc cosl of.ompc.srrio.. dtmgcs as Pnvidcd lor thc
<br />IhcrchtalltnuM$lroullyolpcrjuryrharIa'!lictrsl!.rproviridrotCnrtrcr9(connNncinawirhSn-'rn'n?m0)ofDivisn,l
<br />or
<br />'hc
<br />ausincs( Md Profcssior\ Codc. d my,iccn{c n in lull foEc xlcff.cr
<br />qaualcuQl{IENDlNc-trGElljr
<br />I h.rchy arfirtu utulrr txtrllryorFrjrryrl rlBc i!0 con(rucri(n, lcndins JE.n.y tur rhc Fforntsncc of dc work lor which ihi\ Is'nit i\
<br />i\\u.n (S.c :l(x)?. Ci! C )
<br />ATILICANI.DICTAAAIION
<br />I hctr$y all-rnn undcr prnstry ott)crjury.m ol rhc ldlbvinB dNlnrations:
<br />ttnnlirion Pcrmih-Ashc(os Norilicatio. !;cd.El R.gohttunr (Tnh 40. Pfi6)
<br />-Rcq,ircn
<br />krrcr otNdifi .rrion
<br />I .dify rhst $c lcd.ml rc8lltrlions rg4ding astE(os rcmval re nor aptlicdhk ro lhis lmrcl.
<br />-l
<br />ccnify lhd I harc mad lhh apt,lt.lion un slarc llEr $c otot inaort&rio. is .o@1. I 08re to mnqly *nh oI Cn, and Coury
<br />o.diDnes .Jd Srdr. Lt$ ml,ri.E ro buildinS conrMrbn. ad h.Eh, ulrlF&c Eprcstllivcs of lhk Cily ond Colnty to cnld unon dE
<br />rtx,v. trrcnri0rd pn'pcnt tur nNF.r
<br />Applient or AEenl Si*tulurc:
<br />UNDER GROUND
<br />Waste & Venl
<br />Water-Under floor
<br />Gas-Underfloor
<br />Building Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarif ier
<br />Waste & Vent
<br />Water Pipinq
<br />Gas Piping
<br />Rool Drain
<br />Tub/Shower Test
<br />Rouoh Water Heater
<br />POOL/SPA
<br />P{rap/Drain Line
<br />Main Drain/Pool Pipino
<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 />Rouqh Plumbinq -t u(li+1c)\
<br />Final Gas Test U \,
<br />Meter Release A\
<br />FINAL -7-20-lt,X\4*1^
<br />Notes, Remarks, Etc v
<br />ID/SIG.
<br />Sccrn,n 1076.frhc ljbor Codc. inr.rc{ nnd anofty s r*
<br />.-,-"-,F
<br />t.dn s Nam
<br />-
<br />L.ndcr. Addrc\\
<br />--,.,"
<br />6'b'\[
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