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PLUMBING-INSPECTOR RECORD
<br />APPROVALS COMMENTS
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floo
<br />Gas-Underfloor
<br />Buildin Sewer
<br />Area,/Storm Drain
<br />lnterc rl Clantier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping @a)uA
<br />Roof Drain
<br />Tub/Shower Test
<br />Rou h Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />l\rlain Drain/Pool Pi n
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Gas Service
<br />Water Service
<br />Lawn S rinkler
<br />Back Flow Device
<br />/4,
<br />BSCSh Plumbing qa'/-1>lg )r.vh$
<br />Final Gas Test \-/
<br />Meter Release
<br />FINAL 1 //4{n
<br />Notes Remarks Etc
<br />(,IVNI:R BUII-DER DT]I-(]ARAl'IoN
<br />I hcrchy {flnnr uidcr Nnrlry r, Erjury rhd I d uxcmpr tiom rhc c(,trrd.fttra t-icrnsc Lrw a.r rhc foltowin! r vrn ts€ 7O3l l,Bu\inc\s md Proltsi( code): Any Ciry or counry shkh Eatuncs I {lcrn ro ..n{tucr_ rlrcr. improvc. d.nslirh or Npan any
<br />sd.rut. lrior n, iN h{iR.c. rh. rcquires ihc ll,|licntu r.r skh ri.r,n lo filca si8trcd sofunrnr rhrr hcor shc n ticcn\cr, pu^uanr
<br />k, rhc pmvisidN .r rlf conracror\ l,iccn\cd llw (Choprcr 9. CoDnncn irs sirh S.crnrn 7000 ot Divisiotr :t ot rhc Bu\inc$ i,id
<br />Pmtsrnnr\ Codc)orthlrh.orshc i\ crcn,fl rhcrcti.D0nd ihc h$n turrtr rllcs.dcrcnDri r Anyliotarion.tscclidrT0l.5byany
<br />rprlicanr,oru pnnir luhjcckrhc rpplicu! ra n civil p.nall, .l mi nxrrcrhri tlvc hurtrcd doltus(g5ur).
<br />-1.
<br />a owm of $c Follny. or my crplo)es qnh *.8* .r rlEn sb .ohlEn$rhn, *ill do 0E sork ard rlr lrrur@ ir mt
<br />inlend€d or ofls.d tor sk (Se.7044. Busimsi ,rd Prof6sioN Code Th. Conrractor's Liens t w doc. .n awl, lo d owB of
<br />thc Fopcrty wlE t{i(j oi irlhB tlE6n. &rd sho des sxh wo,t hi@tf or lErstf or lhh.Bh hb or ha, own.mohyer.
<br />Fovidcd rli.r Nch impoEmilr e ft, intc.t d MoIrcEd ttr $L. r. ho*E 0E hitdin8 d in{mwc, Lr $ld wirhir om Frof onpbrior rlE OsM Buit( wi! haE rh. ho,n n oa pevin8 du tE or rlE dil rct build or inp;r dc |'lrsty fm rlE nurF,E ot
<br />_1. as owncr of rhe lmncru !h crclusivcl, .onradinS with li.cn{d .onrado6 to @nsldct th. Im}fl (S.c. 7044. BuymsaM P,riixsbn Codc: Th. Conr&lois Liccnsc rrw d@r not q,ply ro d ow.o dfpmpcnl wtb buit& or imfforc3 rhcr.on.ond who .onr@ls lor ru.h piDj($ wnh r Conlndo(i) l[cncd poNanl to rh. Coni.rctdir Lic€is L.w).
<br />-l
<br />amcx.nrlr rndcr Sstio
<br />woll(nlls' coMPFNsaT(tN
<br />IEC!.AXATXON
<br />I h.rcl,y affirn undc. Fmlry of pcrJrry om of rrE fotlo*ins delmlions:
<br />-,
<br />havc a.dwill mintlin r cc dirrare o f Conscnr ro s.ttt.s!rc ntr wortcr' conFnsdion, a\ noyi{icd ior hySeri.n t7o0 ofrhcbh" Codc, for lhc l).rromnc. of rhc wort for *hi.h rhc pcmir h issu.d.
<br />_lh,vc..d willmhintlin wo*c conD.n\arion insur!rc., as eqxiEd by Sccr ion t?00 of dc tlbor Codc. fo, rhc pcrfonMncc of
<br />thc work irr which thk lErnir is issuol. My *ortc6' $nFnsdion ins!tucc catricr ard Ftkt numb.r dc:
<br />-l
<br />c.dify ih in rhc lcrformns of ihc port for which rhh p(mi i3 isslcd, I shal nol cnploy a., pc^on in .ny tunrcrs N lo bc.om subier io lhc eltss smpcnsrion lass of Crli,omio. and agrcc h.r it I should hc{om subjd lo [E
<br />workcB' .ompcnsdion phvisioB of Sc.lion 3700 of rh. tibor C.d€. I sh,lt. fonhlilh orply wirh rhos lovisiont..
<br />WARNIN(;: Faihrc ro scm wort$J..'npcisarion olcr08c n un \h!ll subjcct m cmpk,lrr k, dihi'rl ncuiri.\ rnd
<br />civil 6n.s up ro onc hunlrcd lfiouend doll& (Slm.ooo). iD addtr co\l olcotrllrcnslrn'n, d,::Q:io?/i:
<br />lrl'( lI n lad flON
<br />I h.r.h, trllrm undcr F* rlrr of ntrlury rhal I rm li$i*d utuler pmvndr of Chafrcr 9 (.onnruc in8 wirh Ssrixr T(xlo ) oi Dtr i\n,n .lol Ihc Ansinc\sand Pre,i*ions Codc. ond nrylicctrr i\ in l'utttir.c d.ff.cr
<br />r>7o*,er(zk* c*,*,,,
<br />C(TNSTRIIC-TION I fNDIN(: AGTNCY
<br />! h.reb, rfirn undcr p.nelr, of pcrjrry rhar rhsc n n snsrturhn tcndin8 lgercy tor $c p..fo@trc .I rhc wo,k tor which rnis trrmn ir
<br />i\sucn (S{. 1097. Civ C,)
<br />APPI ICANl' DECt ARATIoN
<br />I hor+t lnianundcr Fn,ht orFrjury onc olthc r('llosing dcclantiotrs:
<br />I)cmlilion P$n!r\ Arhc\ro\ N.lific0rion Fdl.ral Rc8ul riflrs (Tirtc.r0, Pd6)
<br />-Rquircd
<br />tJ(.i or Ndiff,ltion
<br />-l
<br />.cnif, rhar thc tuml rc8oh(oB rcgsdinB sbcslos ,!mht e not lppttsbk lo tht pmirt.
<br />_l ccnily rlN I harc fid rfih llplical {rre rhit rhc itrvc nrfontur
<br />odinorcs ard Sratc Llws Elalirg rclrcsnlsriv.s oalhis Cn, ud Counrylo cnrs lpon ltr$.v. nrnttoncd proFny lor
<br />ADDlicnn! or,l!cnt Si!nntu
<br />nzllBl
<br />ID/SIG.
<br />/ lLl \
<br />Gas Pipinq \_./
<br />Sanitary Sewer/Cap
<br />-A^ffil >b\rt AE,f) P.A^I wc J* {- A" dnl fu*!.1-
<br />Policy Nu mbcr:-Evi6\: _
<br />I agre rocomnly*ilh allCiiyrid Colnry
<br />^,"0{P//<
<br />I DATE
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