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PLUMBING.INSPECTOR RECORD
<br />APPROVALS DATE IDiSIG.COMMENTS OWNER BU!LI,,ER DEI,CARATX)N
<br />I l(rchy rflnr rtrdcr l.nllrl rn tcljury thll I ar cxcmrr riom rhc Coitr.kna I-i.cnsc tjw for rh. tdlosirr-s rdd$n (Sc.70rl s
<br />Busi.cs\ rM Pn)fcssi(r Celc) AtryCilyor Counry shich rcqutc\ r t^_nnn ro con{fl,cl. rher. inlPn,\c. dcnn tl',{i.l{r dtry
<br />(Ncrur.. oid ro irs i\unc., rt$ r.quncs rhc amli.rnr tor such rnnil ro filc a sigocd nrtnr.n( rhd hu or rhe h liccn{d lu^uut
<br />lo rhc lx)visios ol rlt Cortrrclois l-iccns.d l-r* (ChlPr.r 9. ConnncnciDg sth Scclion ?UX) of l)ivi\rn:l oflh{ Eusinc\r and '
<br />l,mlcsloN Codc)orrharlI orshc iluc itr ihcrcliodnnd rh. bisi\ turrhc illcgcd crcn{ri{,d AdyliohlnnrolSccrionT0.ll5hynny
<br />rprli.r ror pcrmil suhjc(( rhc amlicrtrrro acivilpctr.llyol'ml nucrhx fiv.lru drcd dollrs ($5(x))
<br />-1,
<br />a\ owncrol rnc pmpny,or ry c'nployccs wirh wiFcs $ rhcir solc onrrn\lri{{,- will do rh. sork dkl llrc stn{lue is ml
<br />iorcftld or ollircd f(trvlc(Sc.7ll1t, Busircss ind Prclcsnnx Codc: Thc G,nrr ntr\Li.cnsctrwdocsnol$nlyr('di.$n$of
<br />rh.!6fchy Nhobuildsoriuirncsrhcmn.andNhod..s\u.h*orkhih\clforhcrscliorlhou8hhisorhcto* c'nllolccr.
<br />p'ovidcnrhllsuchipnNcnxncdn.rintc,rl.doroffcic{fdsdtjIl.lmwcvcr.rh.buildinSori'nptulcirtrrisndNirhinnnc$tr
<br />.f..mdcrir\ rhc Owrcr Buikhr *illhf,rt rh. hdr.t notpn,vi'rs rhrr h. or rl[ did rer tnild or i,\rovc rI€ Pr(,pcny ft* rlt PurBsol
<br />-1,
<br />!s oener of thc pmpcny. .m cxclusircly .onrrcdng with lic.n*d conlm.t 6 to co.slocr rlf, nojer (Se. 7044, Bulin sr
<br />and PDtussion Codc: Thc Conrklols Li.ctrsc tjw docs nol apply lo 0n owner ofprepeny who builds or imPrcts lherNn.
<br />and who mnticls aor $cI pmjels wnh ! Cootr..to(s) li.cn*d punuabr ro lh. Cldrrcrols Lienr. tlw).
<br />-l
<br />amcxcmpr undcrsccrioo , B. & P.C. for dis ruN,n
<br />l)el2: O*n.r:
<br />III3trEBE:C{TMTENIAITON
<br />DECI.Af,AII]N
<br />I hercby efrtrn under peMl(y of pdjury om of lh. folowing dNlmtionsl
<br />-l
<br />harc aNlwill mainr in,(irnificarcolCotr*ntto Sclf ltrsurc rbr workcs conrr.n\ario.. rr povidcdthrhySccln,n:17fi)orrhc
<br />Lltrtr C{xlc.lor rhc pcriontui.c ofrh.*ork tortrhichrlr |f n[ is i\sucd
<br />ZLl h^rnid will riikin s()rkcs- conr|Ensalion insurancc. !s reqlircd hy sNoon :l?oo or lhc hbor (-odc. tu rh. PcrLrmmcc or
<br />rhc worl ror whi.hrhisprnir is issucd. M)*orkcs com!.nsrlio. ifs,ranccoricrd Policy nun$cr $cl
<br />S+zr-le {r,n/
<br />pnr.y r'ru.t,,Lr.pi,"*6t26nfr
<br />-lccnifyrh{lanlhe!.rlormnccofthcwo*forqhichthisncrhili.L*!cd,Irh,tlnolcnloyanyPc6oninaoyru.nq$ m ro b.sm subif,r ro rh. ertqJ 66Fnerion hws dfcolirdnia ord agEc thrt if I slEuld tEom subi*l lo lhc
<br />workcis omp.nsarion provisions oi sccfion l?00 of rhc Llhor code l $h.ll. fonhwirh cotrplr wnh thoc prolirions .
<br />WARNINC: FailuE ro slic {orkctr .oryc.snlion ovcmec is utrh{tu|, and shall subjccl .. cmrlorer lo dininal Fmlli.s and
<br />civil fincs up ro otu fiundrcd rholsnd dollds ($100,000). in lddilion lo lhe co.t ofcorr.nsalion. damges as t,rovidcd lor rhc
<br />Sdion 3016 oathc Llbor Codc. inrcr.rl md 0nomy\
<br />dlrr/,tt
<br />IIECIASAIIQN
<br />I h.rcby atltm hdcr ptnnlty or pcrjury rhai I i lien*d undcr trcvisnrn ofChapr$ 9 (comrcncirs sith Sccrio. TOu)) ofDivnion 3
<br />ol rhc ltnsincsund Pmac\si.nsCodc. Md.rv liccdsc is i. iull for.c md cfrccl.
<br />L
<br />o /4)^Z,IIA.v 7:)
<br />CONEINUCUAITLENDIXC.f,AINCI
<br />I hcrch! aflnnr nndcr penalryofFrjurylh,t Lr.i\n.onrruclionlcndinSoscncyfttrrhcNrhinumcolrhcBortiotshkhrhiet/-rnriln
<br />hsuc.l (S.. -1097, Civ. C.)
<br />APPI,I(]AN'T DF]CI,ARA'I'IT)N
<br />llmby illnrumlcr Nnrlry ol j)crjrt otrc ofrhc lalkrvi'!8 dd.lnr i(n$
<br />I)cm,liron Pcrr irs Anrdos Norii.riion l'cd.rrl RcEulxri.rr\ lli([ ]0- Ph6)
<br />R.q ncJ lx(.rol Noril. on
<br />lccnilylhot lhe lcdcralrcsulalionsrcp&linsasbtrosr.movile. notot,Dlkuhlc t,rhit pi.iml.
<br />_l
<br />Z4l( ly 'hr t hsr {Jd 'h's l0r Erri.n iJxi nlrc rhor rhc ltnvc iniomrion i\.orcct l08rcc lo conrply wirh dllChy,nd Connry
<br />ordinanccs lnd Srare bs{ (hring b huildin8co.(rucrion. rd hcrcb, aulnorizc eprcstrlttivcs oflhn Citysnd Cou.ry tt cnltr upon tlE
<br />$ovc nBlioned prcIcny for inspccrioi pu.toscs
<br />/\|lPlicnnl 0r ,\*dt Si*niltr
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Buildinq Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarilier
<br />TOP OUT
<br />Waste & Vent
<br />Water Pipino
<br />Gas Pipino
<br />Roof Drain
<br />Rouqh Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Main Drain/Pool Pipinq
<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 />Rough Plumbinq 5/
<br />"16 ,-x 2I'rfJPdl
<br />Final Gas Test
<br />Meler Release
<br />FINAL 5/z \/(, q-;ftt-tfvgL
<br />Notes, Remarks, Etc
<br />llndfl s Nsm
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<br />*," 5/@//E
<br />Tub/Shower Test
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