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APPROVALS DATE ID/SIG.COMMENTS Ownd-B!ildcr Deladi@
<br />I h@b, aflifr udq po.lry of Fjo.y lhar I & ddpt fm ln. C E!.16'Li6* tlw aor rh. following r6on Ge 7Oi t.5 B6in6t
<br />ad Prof6sion C!dc): Aiy City Colnry whicl r.quid ! FEir ro qdEr.uct, .lcr. improv., d.holnh or r.p.t ey sruclu'., pnor ro 'Ekrusc., also ,cquiB lt. +plior fq $.t Fmit ro lilc s sigrd rr.t@6r thc hc tr 5h. ii li@scd puBuol ro ln. provisio.r of $.
<br />ConE&ro* Li@!.d lls (Ch.fln 9, C.nMdnS wirh Se(on 70@ of Dilti@ I of th. Bcin6s and pr6f.$i@3 Codc) d thlr hc or
<br />shc h q.mpl lh!rciion &d li. bsi! fa 6. rltcBcd .xdpti@ .An, viotiri@ of Serio. 7Ol I 5 by uy .Dplic.nr f6 r ,Gmit subjels $.
<br />appliMt to a .ivil p6dry ol nor m@ $a fiv. hundr.d doll6 (t50o)
<br />_1, s oma of 0'c Fo?cny. r ny dployqt! pirh s!86 s rhct sol. c6fdt!1iotr. vill do $c work ud th. slrvcrur. b nor int nd.d
<br />or o,Ied fo rdc ( Se.roa4, BBin4 ud PrctdiN Co&: rhc Conr&(d's Lica& tlw dc nor appty b e oMF ol $. Fopdry
<br />who buildr d imFovd $a@, ed ,ho dd .uch wo* hiruclf or hdrclf ( ihugn hir d ha om hploy6, Fovid.r! 0 !u.himprovndri E nor intod.d d ofcr.d fd ..1r. Il h@aa. rh. blildinS s iEprov@i ir lotd wirhh d; y; or .@ptaioo, rr.
<br />Owna'Build,6 *ill hlvc $. bunla of Foviit 6at h. d rh. nor build 6 iDFovc fa lhc Ftrpo3c or 3.1.)
<br />_I, q ouaof rh. prcFty. M qclsiv.l, ont !.rins wilh liccnr.d 6r&ldr ro c6rEu.i rhc prcj.d ( Se ?Oaa, BBins MdPrcfBlio Cod. Thc Contr..!d'r Licae lrw dod mr .ppl, ro u own6 ofFopnty who builds c inprovB $.tM , s.t who
<br />conr&E fd '!ch
<br />prcj*r! pnh r contrsd(3) li@.d poMr ro rh. c.nE*lqr u@s L!*.)
<br />_l e .xmF od.r Se{6 .8. & p C. t lhi. l! ron
<br />DLi Omc
<br />WORKEII,I| COMPENSATION DECLATIATION
<br />I hftby .mm @dc pa.lry of pdjury 6q otrh. foll@ins d.cladio.r:
<br />_l havc ed will h.inl!fi ! Cdjlic.r. o{ C.|er ro S*lf-lnruE for edta' cmpd!6rid, s Fovid.d fo b, Sdion l?Oo ofrh.
<br />kbor C.dc, fo. thc p.rrm{cc of lh. wdt for whid 0F p6n i! i$u.d.
<br />_l h.v. Md willn.intaii rct6 .@pdEilio iNMc., s r4uiEd by S*rion 3?oo of lh. Labor c.d., for $c p.rfom&c. of rhc
<br />vort fo, which $is pmir is isruld My wdtd' @mFneri6 inroEcc Mia &d policy numbcr ar.
<br />A^*,,,^,^.
<br />4-cM. ija' ro
<br />'h.
<br />h. @mplald ifdEF t n fq Or. hundrd dolla (SI00) dle)
<br />Ffmee of lhr wqt forwhichthi p.mn is issu.d,lwdl6 ' .@ras.lio l.s of C.lifhiq Md !A.e
<br />of S..1in 3700 ofdr L.Dcoc-
<br />Failur ro i@uE *dt6' c@Fr5cio @vd.gc !!bj..l e dployq ro diminal ,.n!ld6 Md civil
<br />finB up to e. hu.trod $@od dollB (t I oo,ooo),i. sldilion ro lhc 6r
<br />!h. L.bo Cod., intd6r Ed.nmcy'3 fc.3.
<br />conp.n$tion, damag6 a providcd ld tnc ScqiM 1076 of
<br />LICDNSED CONTR^CTOTtS DECLAR,{TION
<br />I I h@by rfrm ed.r pd.lty oapdjury rh3r I d li6*n undr ploviiio of Chsptr 9 {
<br />th. BEine ed Prcrdii@t Cod.. ed
<br />'rry
<br />lic6r. i5 i. full f6e ed.rcl.
<br />-o
<br />I h@by .fiim u<t r p.nilty of pajury rha rlot ir r .druaim t
<br />i!.ucd (S.c ,0c7, Civ. C.).
<br />.8@cy fd $. pcrfmecc oi
<br />'h.
<br />wo fo wh,ch rhis p.mn k
<br />A'ILICANT'S DECT.AF IION
<br />Doolirion PmiE-A,b.it@ Nodficlrid F.d@t R.S{l.rdr (Tnt 40, psr 6)
<br />_ R.quir.<l Llaa ofNorilicrdon
<br />Ub City &d C@nly lo 6rd up6 $!
<br />abovc mdtiocd ,rcp6r, fd irrFcti@
<br />ab.ioi m!v.l d. nor rppliollc to rhi!
<br />gi4
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Underfloor
<br />Gas-Underfloor
<br />Building Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarifler
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Pipeing
<br />Roof Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOUSPA
<br />P{raplDrain Line
<br />Main Drain/Pool Pi ping
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Misc
<br />Gas Service
<br />Water Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Rou gh Plumbing
<br />Final Gas Test E'\T II
<br />Meter Release EEONI ' ltf0
<br />FINAL IAMC 0-4at. 2(0, 556, 667
<br />Notes, Remarks, Etc
<br />PLUMBING.INSPECTOR RECORD
<br />Back Flow Device
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