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PLUMBING-INSPECTOR RECOFD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BI'ILDET DELCARATION
<br />I hcrcby llIm undn p.Mlly of pdury th,l I u.icnpl 6om ttE C., rsdo6 Lttne LlP for ilE tollowitS M$n (S€t.7031-5
<br />Busimsr .d Proa.sior Codc): Ai, Ciry or Coltl|y *hich rcquirci. For lo o.rru.l. rlls. in{,rclo d.@lish d e!6n uy
<br />{rucioe. prir ro ts is3u.G. rlm cquiB lh. imlter for such Fmn to fib . sigftn .urcMl lh.r lr d tlE k lien*d PlNurl
<br />b ln. prcvisions of tlE Conrmld! Ucnsd Ll* (Cltsprc, 9. ComfteitrS wnh Sc.lid ?00O of Division 3 ol r* 8!.imrs md
<br />Ptuf.ssionr Codc) or rhlr h. o, sh. i..rcn{,t ds!.foms.d rhc b.ris fo. thc dhS.d.t plio.. AnyliohdonofSdbn7011.56ye,
<br />alpliclnr ror ! p.mir sbiNls rhc applker ro r civil p.Blry or nor mrc rhs li,e hlndrcd dollas ($500).
<br />l. $ own.r ofth. IrcFny. or my cmplotecs wirh qlgcs as lhcir solc smr.nlarion. will do $. sdk .id llE slrEtE i\ ml
<br />inlcdcd or oficrcd for slc (56,7044. Businc$ ..d &otcsionr Codei l hc Co.a.cbls Licds L!* dNs nol ,!dy lo M owno ol
<br />rh. poFny wh. build\ or in{ms l,Emn. ort who dm srh Mri tims.lf or hcmlf o. rh@ugh his 6r h.r oen employecs,
<br />pFvid.d ihat such iqrroEmntr d nol int.d.<l oiofi.rd forelc.lt howE, rtE buildiB or itrprorcmnt is $ld wirhin onc FU
<br />of€r{,l{ior, 0E Osn.r Built r will harc ttc hidcn of proving lhll h. or shc dil mr hild or inpmE dE FotEry for rhc ntl,. of
<br />-1,
<br />s owr of rh€ pmp.ny. m.rclusivcly conlrdi.S wnh [cnscd mnlmtoE lo onsmcl tlE poir {Se. 7044. Buimrs
<br />lrn ho&sih Cod.: Thc Ci.tnclor's Li.cnic Llw docr nor apply ro u.w.d of pEp.ny who blildr or impret. 1h96..
<br />,id wh6 coi(d3 tor su.h ,mFs wnt r Conrrcro(s) litns.n purtunr ro rle Cofl.&lda. LieB tlw).
<br />I rmcr.'npr undcr Sc.ti0 A. & P.C l'orlhis,c!{,n
<br />UOBTEf,ILS)MTINIAIION
<br />DECId.BAIIQN
<br />I h.r.by rm.nundcr p.nalryof pcrjuryoncof lhc tullouin8dalualiotrs:
<br />I havc dt will roinr.in a CcnifEnl. of Consnt lo Sclf-lnsurc lor wortcF .osntn$raon, .s tmvidd lbr by S(l ion 1700 ol tnc
<br />LsDor Codc. fo,lhe pcdotuc. of fic *ort( lor which th. lcmil is is*u.d.
<br />.fI h,!c rnd s,ll nE,nr,,n worlcs cnmncnsdnnlnsurrrce.!s.cquiEdl,ySdrionlTmoalh.LaborCodc.forlll.poto,lMc.or
<br />th. *ort ror whah this lcmil is iss.n. My sorkos. onqstrerion inruhncc.rfi {n |rlty numb.t uc:
<br />5+a\a FJ\.../
<br />9lZ6 /t1
<br />-lcnilythatinthcpc'ornunccofrhcworklorwhichihis,'crnirhhsucd.Ishlllnotcmplo,uypcroninlnyn'lnror$ aqr. bccom rubiccr ro th. workc!(compcns.iion la*s ofC.lifortri!. Dnd ugB thul itl \hould h..om subiccr to llE
<br />w.rkos odpc.sarioi,mvisionsolscclion37IxJof$ct bor C.dc. I shull. fonh*nh conply wirn tho* ,rcvisions .
<br />WAINING: Failurc ro $cm *trt ra ompcMtion covmgc n unh*tu|. lid shall sbj.cl e cmplo)$ lo 6ini&l Foxa* od
<br />civil aocs up io om hudrcd lho!$nd dolls (5100.000). in addnion ro lhcco of conFMliot. d.m8ct a prcvid.d fo. rlE
<br />Serion 1076ofllEt bor Codc, hrcrcsr and 0rl(,dy s 16.
<br />-'.5\ l()/ ltr
<br />DECI,IAAIION
<br />t h.rb, umlnundcr ncnshyolp.riury rhd I rN li.c.rd undcr Inlvhion oiChaprc.9 (€mmn.ing wnh Setion ?fil) olDivhn$ l
<br />ol' thc Busincssand Pm,bsstun\Codc, drl mylic.n* is in rull aor.u ,i .ilicl
<br />lorf ?3
<br />CANSIBICIXINLENDACTTCEIqL
<br />I hcBby .lIrm uldc, Fo.hy of Fdury lhll lh.rc b ! @nrtudbn hidin8 a$my lor lhc Frfo'rls. of thc *mi fo, Phth rhj3 Fdn is
<br />hsuc{ tse. 1097. civ. c,)
<br />AIELICANLDTCIABAIIIJ!
<br />I rrn$y anim uM.r pcnahyofncrjuryorc orlhc follo*ins dccltrrions:
<br />llcmnirion Pcmirs Astf,{os Norin.dion Fcdcr.l Rcaubrions(Inlc ]0. Pfi6)
<br />_Rcq!t d lru.. or Norirrardn
<br />I ccnify lhar thc fcd.rll rcsrlations esstdin! !srEn.\ icfrrrdl d. nor 0ldiclblc to this tmj.a1.
<br />411(cniayrhd I h.!crcrd rhn.prl*arDn.ndnorcth.t lhe ahovc informlion h cotur I r8,d ro omrly snh lll Cny cd Counry
<br />otrtinanccs a.d Srar. Lies rliiing b buildin8 con(ruclion. lnd tcrcb, lultrrit dpE{nrdiws orrhisCiryand Countyld cme ug,n rh.
<br />above mnrioned pmteny {.r ins&.rion ltrrFsci
<br />Applir nl or /tgrnl SiAmtum:b,,' 6/lOllt
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Buildino Sewer
<br />lnterceptor/ Clarilier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Pipinq
<br />Roof Drain
<br />Tub/Shower Test
<br />Rouqh Water Heater
<br />POOL/SPA
<br />P{rap/Drain Line
<br />lr/ain 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 />Rouqh Plumbinq fii:rt/z ,-El U-a).t*
<br />Final Gas Test
<br />Meter Release
<br />FINAL #Vn 5--re,'t2n+K1
<br />Notes, Remarks, Etc.
<br />Area/Storm Drain
<br />,"., e/n/ll
<br />L.ndst Addt$:
<br />-
<br />I
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