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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.OWNER BUILDER D!]LCARA']ION
<br />I hfi.by alir rndf l.n,hy of F.lury dar I dn crcnDr rn h rr* Conhdos Liccnsc L,w for lnc n bsins rca$n (S$?0:1,5
<br />Ausincss anl P,oi.stu Codc) A.y Cily o! Coutrry which rcqun$ . FamI h .on(dcr. lltcr, inpn*!. dcnblrrh or rcprk ,ny
<br />sn,cr!.c. priff lo irs issusne. alv' rcqon r rhc a0pliclnr nn su.h pcmir lo fik d \iBmd d,rcmnr rhd h. or shc i li.cncd puBu0trl
<br />lo rhc pmvhions of'tE Conlmclols t-iccnsd tjw lctnplcr 9. Coarnrcncin8 uilh Scclion 7(xl) oI Di!i\n,n I orrhc 8u\inc$ and
<br />Polc$ion\Codc)o!rh.rlEorshci\cicmprrhcrcamma,rhcn\haorrheolLscdcrcnnrhn nyvnrhrionofs.r'i,n?03l5hyrny
<br />aptli.,d rofu Fmir subj('s rh dppli.a.l ro n .ivil pcnrlrr of nor nkrc rhln livc hundrcd dollars (SsrD)
<br />-1,
<br />!\ osncr.l lhc polrrit. or m, cmrl.r!.\ wnh wssc! !\ rhct vrc $mNn{ n,n. *ill Jo rh. wo.k rhcslMurcismr
<br />i cdcd or olta(d ror $h (SN 7(}1,{. ausi*$ atrd Pr.lcssions codc: Thc Contr&ror's Liccnsc liy docs nol amly ro aowncrof
<br />rhc pmrcnt sno builds or nnpmvcs rn{dn. ml who de\ s!.h so* himsclfor hcAclfor rhtuu8h hn .r hxr own.n[k']ccs.
<br />prvidcd rhsl uh impnxc'Eoh @ tror iorcalsl.r oaltrcd lor solc li houckr. rhc buihirg or i'lprotcar is i,ld *irhin.iu tt,tr
<br />oi <nnpkli'n. thc Owmr Bultlq sill hle
<br />'lE
<br />budcn of pmvirs lMr hc or \hc da d t,ild or ir{)nrt lh. ptr,p.i, r(, rrr PuiF{ or
<br />-l.nsowncrolrh.trepcrrr,amexclusilclyconrrlcrins*irhliccnsdconr.lcbrrocon(tucrrheprjr.r(Se
<br />7014. Bu\ircs
<br />rnl Eot\\irn Codc: Tnc Coitdctr'{ Li..nsc lis do6 nor rprly k, M oqnd .a p,op.ny *ho build\ or inFruvcs rhcrcon,
<br />and who 6.l.ek lor 3En Pllj.lls ,ilh ! Conlra.r.(3) licD*d
<br />-l
<br />!mdcmpl undcr Scc
<br />s/pa-fi{
<br />I hcrcby liln'n undcr pcnrllyolFrjrryorc o,lhc rollowinB dLrld.ark,trr:
<br />-lhNcmlqillrnli.na(tnificrlcofConscnrhScll.lnsurelirqorkcrscorDcnsdion.xsF,vidcdrb,byScrionl7U)ofrhcL.titr Codc. ln,lhc pdnnrurEc orrhc work lor whichlhctrnnn h hucd.
<br />I hr!. rtrd *ill nEinllin *orkcra conlr.\{ idn i.{urrncc, r\ rqunl{ by Ssr nr 17{x) of rhc Uhor Codc. lor rhc Fiomncc of
<br />rhc sork lrtr shkhrhi*Frmir ir t\ncn. My uork$J .otrD.nstrrion insurmcc.rnicr nn poticynumbc.m:
<br />-l
<br />ccniryrh,r in thc pcrformmc of rtc wort fm whict rtis pcrmir is hsd I shall et cmploy any F^oo i. a.y 60nmr
<br />r, N ro bcNnr rubjfl 16 rhc M,l(6 onp.N.rion l2ws otcrlirom& .nd l8re lhol ia l should b.rom subi€l lo lhc
<br />wortcB cooncnM(iontovnions olSccdon 3roo olth. Lotor Cod.,I shlll. fonhwith€otrUly wilh lhoF [,mvisin*..
<br />WARNINC: Failurc ro suE workc$ @npcnqrion coErasc Ls un
<br />hc co$ or.6,-*i*t
<br />.nll)loFr ro aiminal ,Emllis and
<br />ion. dnnuges !s proviicd aor lhccilil lincs !p to one hundrcd thousnd dollm ($100,000). in addnidn
<br />sccrt,n 10?6 of rh. ljtxr Code. inrcrc{ sd arttrer\ lccs.
<br />I hcr.by af,nm und.r Fn,h, ol p.rjury rhnr I n liccn*d u.dd In liraon ol sn'rcrcins with Sccrion 7([x]) orDivtion l
<br />of the Busituss and Pofcasions Codc. !d my lhcns h in full toN ad cftc.l
<br />l-iatr$ Chss
<br />-Liccnsc
<br />Nlhber:
<br />Dit.: Cortalor:
<br />(aNEIBIJSIII}N.LENDINC.&CEX.CI
<br />I h.Eby lffnn und.i lxndhy ol !.rury lial lhcE h a onsldcrbD bndinS qcncy for lhc pcrlbrm@ or rhc work lor whi.h thh Fmir ir
<br />kxocd lss. 1097. Civ. C.)
<br />A.STLIIbNLD&SLABAIION
<br />I tErch, !flinn undcr p.n!h y of pcrjury orc ofrhc bllowing dc.lrdnrN
<br />Dcmlirion Pcrmih-Asbesros Norinolion FcdcEl Rc8lllrion\ rTnt.r0. PM6)
<br />-Requtcd
<br />lxllcr of Noriarclrhn
<br />I ccnilyrhtrr rh. IcJcrrl rcguhrn,ns rgarJinB
<br />-l
<br />ccnify lh0l I h,vc rcad lhk applicalion ard s lomrion Lr co@r. I .8re lo .otrrtly with aU Cily 3nd Colily
<br />ordinotrccs.nd Slurc t wsEhrinS robuild lulho ar.lrc*nl ivci oflhn Cirymd Colnryto c.tcr utnnrlE
<br />{horc mnli.Ed ImFny for
<br />.{Dlicrnl or.\!ul Sir h,r.:""", {/pa-/tg
<br />UNDEB GHOUND ,21^o,\
<br />Waste & Vent Y7
<br />Water-Under f loor I ffi-
<br />Gas-Underfloor
<br />Buildinq Sewer
<br />Area,/Storm Drain
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Venl
<br />Water Piping
<br />Gas Pipino
<br />Boof Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Main Drain/Pool Pipinq
<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 lB 6lrr r t?>)
<br />Final Gas Test U\
<br />Meter Release ,4.
<br />FINAL l-rl-7,0 $.[/'it)
<br />Notes Remarks Etc.
<br />COMMENTS
<br />Fill Line/Back Flow
<br />/t"",.' 6ft?lts
<br />t ndcis AddB:
<br />-
<br />L,...--
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