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PLUMBING.INSPECTOH RECORD
<br />APPROVALS ID/SIG.COMMENTS
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under lloor
<br />Building Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarilier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Piping
<br />Roof Drain
<br />f,ough Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />lvlain Drain/Pool Pipinq
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Gas Service
<br />Water Service
<br />La wn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />Rough Plumbing
<br />Final Gas Test
<br />Meter Belease /^\
<br />FINAL +-1-l'1 .Y-lqrl0l
<br />Notes, Remarks, Etc.
<br />---D
<br />OWNER IIUILDER DFJI,CARATION
<br />I hcrc$y iflinn utrd.r pctr i oflcrjury rh l rncrN$ ft,n rhc G)nkNbs-Li.cisc bw rar Ihr tullosing rcren (scc.?oil.5
<br />Bornrcss nnd Prcltrsi,m Orlc): Any Cily or County s[i.[ rcquncs r p(irnir lo cotr{ruci, nltcr. iDpruvc. dcmoli\h or rcpln any
<br />sru.rxrc. r,atr t, ir! n\un.., ah. rdquids rhc lnllica tu such Nnnir h fiL!lilncd {rrcmnr rh( hcor shc is liccnscd puru8nr
<br />ro rh. pnvisnnF ol rhc Conl,acrols l-iccr\cd tiq (Chrpr.r t), Connncrrir8 wirh Sccrn,tr 7uD ol Division I ofthc Busioc$ rnn
<br />Pn,rc\\ion\G'dcr.rrhar tE or\hc ircicmpr thcrcr'roma lhc hffn r'o.lhc lllcscd crcmrlnrn Anyriohi.nofs(lnnT0-1l5bruy
<br />!!fli.ddturr|lmirsuhjNtsrh.aprlrrnrk,r.iviltcfulryolnor,norcrhanlivchrndrcddollds($50{))
<br />_1. a oq6otrh. ptuFny. d
<br />'ny
<br />chpkrrca {irh wl8.s a t n $b oEFEsarion. *iI do dE mlt lin dr sritre i, mr
<br />inlc ld troiircd lo slc (5e.?044, aBire$od PDfc$io6 Codq ThcContocror's Lltn* Ll* do* rct applylomowMol
<br />ll* ristEly who builds or inprDE lhoEn. rnd who dG trh wrt hiNclf or h@lf or lisrSh lt! o hs oq .nploy.*.
<br />pbvidcri rhlt.uch in{hwc.ts c Dl htc'icd s otr@d lor Flc. lf. h.w6. IIE toildinS or inpllwrnt is $ld vtrhin om )srofonphtiotr tlE Ownd B!U&r wiu hlw dE hrLn of poring thor h. tr sh. dil mr b'iilt or irp|lE 0E FDpsry for dE purpo$ of'
<br />-1.
<br />is owncr of rh. Dmtdy, amcxclusivclyconracrine wirh liccn$d conrErorro dnsdcr rhc pmitr (S.c. ?044. Busmss
<br />and &!i:$ion Codc: Thc Confacror's Liccns Low docs ml rpply lo an owncr of pmtcrly sho builds or imtrcvcs lhcrsn-dnd *ho cooh.k r(tr .uch l6lrk wnh n Conrrcro(9 lten$d puFMr ro fie Conrldols Lkcn€ Law).
<br />-l
<br />ad crcqrr und6 SNI B & P.C. tor rhis rcN)n.
<br />}OBf,EBS:CqITIEMAIIAN
<br />PECI.AEAIITTN
<br />I hcrby lfirn undo lcn.lty of Isjury onc of ttrj folloains ddlerrions:
<br />_l hrvc ud *ill minrain a Ccnitrarc otcon$ ro Sclf-lnsE aor work6 dn{rcnslrion. s Fovitcd for b, Serio, l70O 6f rL
<br />Labor Cod., fo. lh. pcrfmmc of llE sork tor whi.h lhc l,cmn n issucd
<br />I hnvc rnd will tui'nain woikcrj .oqf,n\arn,n in\rr!n.c. as rcquiEd hy Sccrn,n ll7fll oI rhc Lil,or G)dc, ror rh. pdfolmm ol
<br />lhc work for ahich rhisFrnrir is irsetr. M,work.6 comrcnsarion iNlrrE. crd.. ud Frlicy nnmhd ml
<br />-x trnify rhlr itr lhc pcrfsdmc of llE sork ror wtth lllt Fr6ir is issucd. I s l nor cmploy sny p.Mn in uy ms*r
<br />s 3s ro b.@m $b.i6r ro rhc ftrks' .omp.nsadon k$ of Califomtu. ud !3N rtar if I stnlh bccoe subicr to rh.
<br />*otle6 onpcrsthn prevhions of SNrion l7m ot lhc t bor C!d..I stutl. fodhvirh 6ry,ty wirh rhos pmvhiors..
<br />I4ARNINC: Failurc ro $curc woricts ompcnsdio. covdn8. is unlnwlul. ,nd ihdl subld tr. cq)lorrr ro aiminll Fmhts lnd
<br />cilil 6ncs up to onc hunnrcd rhousrnd dolla l$lm.(xx)). in ion ro rhc .o of .onqrcnsarion. damSs !s providcd for llE
<br />or rhc L.btr cod., ,?l.En
<br /><,-1n4{
<br />I hcEb, afim under pcnally ot pcrhry $d I m [ensn undcr nofChontcr9(ommncinswithSdion7000)of Divii .l
<br />of th{ Busincss and Poacsionr Codc, sln m} li.cnr n in tull loro rt cfidr
<br />ct0 Ln0 1514a)q-'L7-/
<br />v
<br />CQlilnli1]Il)Nl"l:NlIll;rllitinljlIh.rhIrffinnundcrFrrlrrolpc.luryrhrrrh.'ris!on{ru.lio.tndiUrgrNytnrrhcF-rlnii,' c.olrhc*rknn*hrhrhisFnniri\
<br />i\{'c(l(Sc. 1097. Clr ( )
<br />6.tflICilIfD[CL BTIIIAN
<br />I lrd)y rtfimr undc! ,.nrlly oi rrrjry onc ofrhc li]ll,,wnrr d$lffiliu'r
<br />Dcnnlirbn Pcrnrih-Ashc osNoliic(tion Ftdcral RcSulrrdN ('l Ilct0. Pnn6)
<br />-Rcquncd
<br />rr'lcr of Norifi c.lion
<br />-l
<br />ccnifyrhd rhc acdcral rcBultrrions rcSrding ash.sos rcnx'vnl&c nor 0pdi.abL ro
<br />'his
<br />pmjer.
<br />)&cniry rhlr I har rcad rhis applilario. o.d nlrc rtarthc.hv. nrrornurion is corer.I EEr ro omdy wirh au c'ryand colnry
<br />onlitu .c\ rtrd SirrcLLs\ tob,ii! k, huilding.onntucrion- rat JLrh.,vc " flradrri\.. ur,\'. Cir) rRi Counr, L' cnka uF,n r,,
<br />d/f- h*, .5-''-n 'l{rh,vc NnrnnNd pmpcnylilr intpccrn r
<br />Arplicanl or Asenl SisnnluF
<br />J
<br />I
<br />II
<br />DATE
<br />/"r*
<br />Conmlor: A /4^,"--
<br />Permile nome (pnnt) X L4c
<br />Gas-Underfloor
<br />Tub/Shower Test
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