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APPROVALS DATE ID/SIG.COMMENTS l)\1Nl:l{ Ilt ll.l)llR l,lil ( \ll \ ll()N <br />I h.Eby ftrE undrr I'culry of pcruty rh,l I M cxcq,l film ltE C.ntrado Lic..F tiw tor lhc following rcMn (54?0315 <br />Ausi..s ain Profcssion Codc): Ary Cily or Couniy whhn Ellies a P.rnit ro onslrucl, dld. imprcw. d.mli.sh or({Fn 6nv <br />srructE, prbr b ns i.su!@. als rcquiE lhc appliclnl for tuch P.mi ro lik ! sigNd slllctu lhtl l! or .h. is liensd Fusol <br />ro rh. Imvisions of ltf, Conlhclot r Li..nsd Ls (CnrPl.r 9, C.m'Ercing wnh Sc.lion 7000 of Oivision I ot ttr Buin s 'anJ <br />PrcfcssioN Code) or rhdr h. or sh. is crnpl thEclronsnd lhe b{sir for lhc dll8d crsmtlion Ao, violadoD of Selbn 7Ol I :5 bv anjr <br />afplica for a p.rnir subjcI' lne lppliclni ro ! civil PcMhy of m! mrc lnln fiv€ hundrd dollm (5500). <br />-1. <br />&j owncr of ihc Fmlcfly. or my cmplort s wilh wl8.s $ lhct soL onpe.salio.. wiu do lll qdk &d bc slrudw t mr <br />inllirled or ofiercd for slc (Se.7044. B$incss ud Prof.ssi.ns Codc Th. Co.ltaclols Ltcns Llw rk ca @l q,ply lo an ownf of <br />rlr FDFny who t{ildi or in+ros oton. rJn sho dB sh Mti him$lf o. lEr*lr or rhmu8h hii or hcr own coploy6. <br />0rolidcd rhd .uch iqftrtria N d iitsicd mo,fe,td aor sh. lt howEr.0r hliuirg q oprowmnr is $ld sinh orc F! <br />of€oryhrion. lhc Oercr Bxil&r wil nlw dE budcn ofpmving lhal l! 6. slE did ml b'rild ot inlmw ihc p(Frty ior tlf, lElbs of <br />-1. <br />ai owE ol $c pmFny. !n ciclurir.l, con ldine vitt tiemd .onln.lo6 lo @.tu.1 llE tmirt (56 7044. Aulim<i <br />ard PDf6ion Codc: Thc Conr&lor'3 Liccns Lr* dms ml srply ro d own.. of l"ol,eny *ho buildi or inprcws thcmo. <br />o.d who coir.eN for suci pmj.tri wirh a controdo(s) liersd plBu to lh. co.rr&rork Ltcnse tiw). <br />-l <br />m excrlpr uds Scrion- B. & P.C. aor rht c&sn. <br />goBf,E8li:co!4fENlarloN <br />DEglllSauoN <br />t hcEby rflirn und( ttnllly ol leriury oi. of llt folloeins ddlnrariors: <br />lh!$rtrdwillmrinrlinrccnifi.$.ofCo.scnrtiSellrlNurclin(orkcr\'.ompctr\arion.asProvnhdfdbyScclionS?(x)oIrhc <br />ljhor C.dc. lir r,r Frrirnancc of rhc work ld whi.h rh. p.nnn h isucJ <br />-l <br />hlvc ond pill minldin *orkers con ENltion in$nncc. Ls rcquird by s.dion l?00 of llt hbor Cod€. for lic F fotrj@c of <br />I]crmir ir kkn. MyworkcB corycnsoln,n insurucc caricr od Flicy numbcr @: <br />I I <br />I c.niry fisr in th. p.rforerc olrts pork for *hich lhh F.mir is i$uci. l3hsll ml.mphyrny Dcmn in lny mnE <br />s !s ro h.stu Flbixl io ih. mrtm comFnslb. hws of Cdtifom4 .rd a3@ lhal if I sthnld bocotr $bi(l lo U. <br />*orke6' cotr{rnslrion povisions of Selion l?0O ot lh. lith, Code. I .halL foniwilh omply with rhos Pmvirions.. <br />WAININC: FailuE ro suc wdk r' comrEn$bn 6t6gi ii unltwtuL dd snal $b}tl o .ir'phys lo siniEl FMlli. lnd <br />civil fDcs uti ro o* hun.t d $.!sd dollm (SIOO.OOO). in addirio. io th. cosl of onFtrerion. &mgcs or Provhn for $c <br />:][rfflt?'EIUI;-:, <br />DEEIA.S{IION <br />I hcrb, !rillnrnd.r r..0lryoit'crjury lhrr I sm ln!.\cd u.d.r llovision olChlprcr I (connm..in8 wilh Sccrion 7(xx)) '1I)ivi\ion l <br />of rh. Bu\irc$ aftl I'n,rcrsions Codc. uxi nry li.cns t in tull tlc $d cfitcr <br />.{7,srt {€ <br />'ltA++{ 201S- <br />CONEIBI].qIONIINPINCIGDNCT <br />I hcrcby dfim unicr F lly of perjory rhai lh.rc k a oNlruclion lcndhs lgcry for ltE FYfollrwc ol rhc m.* for *hth lhh Fm! il <br />hsucd (s*. 1097, cir, c ). <br />APILICANLIIICLA8A:IIA! <br />I tmby nni.n undcr pcnnhy of p.rjury onc oalhc li,lln*ing dccloari.n(: <br />Dcnmlirion Pcnnirs.AslEstos Noiin.nrio. Fcd..rl Rcsuurions (l itk 40. Pd6) <br />R.qun d r.trcr ol Norificdion <br />-l <br />ani(y rt t lhc lcdc..! Eslldions Esedins ..belo. rcmvtl N ml sPtlical,k ro Oit poir. <br />lccnifyrhor I hivc rcod rhn aptli.0rio. and srilc lhal tic stnle int rmlbn k coral. I roomply enh oI Cily.nd Counry <br />ordinanccs md St.tc Llws rclding lo buildinS con(dcrion. ond h..cb,orrhisCiry lnd Counry ro cms u,rn tlE <br />rtiM rtrri(nrdl,rofcrly li, in\Fcr ion purB)$s <br />UNDER GBOUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />lnterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Pipinq <br />Rool Drain <br />Tub/Shower Test <br />Rouqh Water Healer <br />POOL/SPA <br />P-trap/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 />Sanitarv Sewer/Cap <br />Back Flow Device <br />Rouqh Plumbinq 5/l ols ,)n LeTui t <br />Final Gas Test <br />Meter Release <br />FINAL z-/?- /a J)t{d+z @) <br />Notes, Remarks, Etc <br />PLUMBING-INSPECTOR RECOBD <br />l,nd.ir Arld,rs <br />- <br />A0pltcaul or AE.nl Siandurc: