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PLUMBING.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.OWNFJR ttuIT,DI.:R T}T.]I-CARATloN
<br />I lf,rcby rfii n u cr pcnnlry ol pcrjury tha! I m cxc'tpr riom ihc c ntn lon Liccn\c l,w in rhc followin8 rcavrn (SL{ 70ll 5
<br />Busnrcss nfrl Prclc\si.tr Codc): A , Ciry or Colnry whi.h rcqurcs a |xdir k, d,n{ .r. hcr. irynvc, dctuli\h ,tr tNn ,
<br />srrucrlrc. orro irr issu..c. rl$ rcquncs lhe $tlicrnl itr \uchrcnnir b iLa \i8ncd (rlcnEnr lhrr l[or \hc is lic.nsed punx0nr
<br />10 thc trovtiotrs of lhc Co rlcxtr\ l-ic.n\cl bw (Chll)r.r 9. Commcrcins silh Sccrn,n 7ffn ol Division :l ol rl$ Bnsin.s r
<br />Pn,fc\sions Cdc ) or lhrr if,or\hc i\cr.n{r rhcrclionmd lhc h$is r'or rh. rlldecd crrmfri()n Anl vnnrrt,rorsc.rionT0ll J hv trn,
<br />appli(itrrntrnp.rnrirsubJcclsrh..ttlicrtrrtoacivil,'cnrhyofnornDrcrh3nnvchuodcddollats(S5o0)
<br />-1,
<br />&r owft, of th. prctEny. u ny.nploFs {nh wrscs 6 ltEi. sh @nF lrior wiu do r!wk.t!d tlE ItEr@ ir ml
<br />inr.nd.d or ofi.ird fd sl. (Se.7Ol4, 8u.iB md lofc$ions C.dc: Tlt C, rd6 s Llre t w d.,cs ml rppty !o @ oM4 of
<br />rlEl,Epdry {tb tdikts 6 irpilE 0E@( rn eho dB *h wt himlf or hcElf or ll!trtd tk ot lEr own.oploy.ca.
<br />ptuvid.d rhar.u.h inFDmire e mr illl€i&l 6 oltErd for s].. tf. ho9!E.llE lxiBhg d inlrcEmt* i! sE sitth oE ,at
<br />olonpLrbtr llE OwM Buitlg *iU lrE rlt Ulrl.n of pdring fid h. o, CE .M mt hild d itrTroE tlE popaly for dE prrpm ol
<br />-1..rowffiof
<br />rlE |'spdry, u.rcfusit! 6nt!.rhB *ilh lided.ot teIoB ro oNnu.1 lh.lrcin (Se. 7014. Busincsr
<br />,nd EDft$io.Con.: Tte Conlftloas Licns Lrv doc. rcl.pply ro rnowner ofproFnyeho build! intpott thdoi,
<br />.nd wno coihi.ls rn such pnifrc wi$ r C. relon9 &srn plMfl ro rhc connclo'3 LiqN ti*).
<br />-l
<br />am crcmpr ldcr Ser B. & P.C. aorrhn 6&vnl
<br />Dere:--_- Oqn.r
<br />ltof,rElsloMrrNsAttQ!
<br />DECI.ABAUITN
<br />I hcrcby alfim udcr pcelry ot pqjury oR .t llE aollowinS ddqll io.sl
<br />-lhovc,rnwillnrnrir!Ccnil-rc,lcofco.icnrn,sclf-|.\xrcforqmtcnodpcns,ri.n.Nl,ovidcdrbrbySccliodlTmofrhcLnbo. C.d.. for rhc pdfoiltffie of thc wort for *hi.h ihc pdnir is ir(ucd.
<br />lillhrv.rndqrll'n nr0ir*ortcr'(,nrl(n\rr'on,nsu.trmc.,srcquircdbyS$rior]70oolthct{hotCod€.forrhcr.dornunccot
<br />rh. *o.k ror whi.hlhG pc,nil is is\Ed Mywbikds L$tp.ns,lion iniut{ncc (Mi$ *rl Flicy lumt'cr m:
<br />Sur<- fi,Y,J
<br />-l.cdiry
<br />rhar in ih. Frli'rmre oarh. wotl fo. *hkh rhn Frmil is ns!.n, I sh.ll Nr cnDloylny lcrson in My @nrc.
<br />s N ro ti.mm subrrr ro rhc mrtqc on{x.salion laws ol Californi& aftl aAEc rhal if I sh.uld lEroE subjccr o ln.
<br />wo sl omlc.s.rn n rftrbions of Selion 3?00 of lhc LitDr Crdc. I slEll, t nhwilh ohpl, *irh rhoc novhbn{.
<br />WARNINGT Failur. lo scuc work ( con{,.nssrion ov.mgc is unh*tuI. and rhJl subicr !n cmtLFr lo oimiMl Fdlris aid
<br />civil fhcs up ro one hunded rh6usnd dollrr (llm,ooo). in oddilion lo rhc cosr olsq,cnsation. d.mees N providcd for lh.
<br />S.ction 30?6 of $e Lltor Code. inrcrc* 8nd dlomy s la3.
<br />F. /rn //qt),r.. -, / lv / ll,, Applr@nl:
<br />UIILABAIION
<br />oi rhc au\irc\\ md Pn)fcsi{nrsC. c, kl nry h..nsc N ilr iulllir.c r .1L.r
<br />lD l--7 q 1 L
<br />C(}i\S RUCTION I I'NT)IN(] ACENCY
<br />I hc(hy rlfirtu und$ ritr.ty of p.rjur) rh3r rhm i\ r roiiru.ri,r lcndiff a8c!.y lnr rhr Pcrf.nun.c ollhc w.rk lu *hi.h rhis !.rnrir is
<br />is\uc.l (Sc. .l(D7. Ci!. C )
<br />A.EPJ,IIAII.DECLII8AIION
<br />I hE-by afm undd peraly oa Fr.iury om of thc following deld6rions
<br />D.mlirion PdmnsAst sro! Norifrcarion Fcdml Rcslldions (Tnb4{l P.n6)
<br />Rouncd lrtrcrufN fsnon
<br />-l
<br />(cnil!rhnr lhc rcd.mlm8uhtDn. rccldin8 lrbcsro\rnnaldc norJPflkohlc h Lhn lbF .
<br />f?fil .d,rv rhar I haw rcsd ,hr lnplkrhon .d (arc rhd rh. lhvc informri.n n cDmr. I asN ro comply sirh sll ciry ,nd county
<br />ordrmftcs and sisr. bws rcbrin! ro bdilding oNfldbn. {'d hdct'y aurlErie tcF.*nrarircs oalhisCnyand Counly lo cnls uPoo thc
<br />lbor mnrioncd pbpcny fm i,s!'elion pqer
<br />Applic!nl or Alrnl Si*nslu
<br />Water-Under floor
<br />Gas-Underfloor
<br />Buildino Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarilier
<br />TOP OUT
<br />Waste & Vent
<br />Water Pipinq
<br />Gas Pipinq
<br />Boof Drain
<br />Tub/Shower Test
<br />Rouqh Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />It/ain Drain/Pool Pipino
<br />Fill Linei 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 1/,2 /!'6 4.:\.QJfrU$3
<br />Final Gas Test
<br />Meler Release
<br />FINAL 5t r/rs , iz i2tyit+#
<br />Notes, Remarks, Etc
<br />COMMENTS
<br />UNDER GROUND
<br />Waste & Vent
<br />p,i"yru*.,,@r,n*., I I 2o / lA
<br />L.ndca" :{am:
<br />-
<br />L.ndd r AddEs:
<br />-
<br />- -,, An/16
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