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PLUMBING-INSPECTOR RECORD <br />APPROVALS DATE COMMENTS <br />UNDEH GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Building Sewer <br />AreaiStorm Drain <br />lnterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Pipino <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOL/SPA <br />P{rap/Drain Line <br />Main Drain/Pool P rprng <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Lawn Sprinkler <br />Sanitary Sewer/Cap <br />Back Flow Device <br />Rough Plumbinq <br />Final Gas Test <br />FINAL 0 (Y tv 1 lKt / <br />Notes, Remarks, Etc.[' r <br />OWNER BUILDER DELC:ARATION <br />I hcrcby aftnm undc. Fn.lry of lcrj!ry rhrr I m cxcnfl tmn rh. Co 0.106 Liens Liw for rlE aollosing rcrsn (s"c.7031.5 <br />Businc$ ad Pmfession Cod.): Any Cily or Cdnly shi.h requiG, Isnir b @oq@( dt6. inprow, deDdlls,t !! rcp3i sy <br />slruclue, prior ro ns isslaftc, s]$ lqliEs rhc applica aor such Fmil ro ,ilc ! sigtud sr0r.mnr rhol lE or shc ii lisnsd';irfuur <br />ro rh. pmrisions of tE ConrEctols Liccnsn bs (Ch4rc. 9. C6nmGing wirh Sdiio, 7000 of Divisio. I ol rlr B$in..s aod <br />Pmlcsioos Cod.) o, thar L or shc h cxctrrt r rhcrcfioh lnd thc hlsk for rhc auc8cd cxcmprion. Any viotalion ofSc.lion ?031.5 by any <br />llplicanl for a Fftil subjets ihc olplic$t lo . citil pcBhy of et mc ih.r filc hundrcd dotles (1500). <br />-1. <br />* o{er of lhc lmlEnr. or nt cn ,lotss *ilh *!8cs as rh.n sb .o.Fns,lion. wil (l! dE *Mt ard lh. rlllxle is ml <br />i cnded m olIccd for sale ( 5&.?044. Blsincs and Prsfessions Cods Tnc Conrractols Licc.F Lsw docs nol q,ply ro an owrcr ol <br />llE toFly who buildc or itrpmEs llE$n. .id wth &B Mh wt* him.lf or h.*lt.r lhrcllh his d h.r ow..mrk yes. <br />lrovid.d thri such iotre\trenB@ ml hrd'dcd orofrcEd for sh. lf. to*r$. rne hiildin8 or inFmmr Lr $ld qithin orc Fr <br />otoq'lctbn. rlr Owr AliEs * hlr rlr hlrd.n of Fovirg oEl hc or shc dii mt boild or iqmh lh. pDFny,or tlr purpocof <br />-1. <br />3s owftr ol lh. lmrErr, ad crchsilcly conrraclins virh liftnpd conlr.clon lo mnsirud llE !,oj.{r (Sc. 7044. Blqrcs\ <br />and Pmflsirn Codc: Thc Conrmrols Li.cnsc ha doci nor sptly ro M ownr otproprriywho builds or inpbt.s &.r.o.. <br />aod rno conrEcls tu sct proj.rrs wirh ! Conrmro(O lk nFd pusuel ro rh. C.nrd.tols Ltcn$ k*). <br />-l <br />rm excnDl undcr Scl <br />Osner. <br />TOBf,EXIII:OMTBSAIIO! <br />DECIABA.IION <br />I h.Eby affirn undcr pcelly of po,trry or ot fic touda hC dNlmrionr: <br />-l <br />hrv. ad will @i.hin r Clnifrc{c of Cooscnl lo Sclllosuc fo. *ork6 @rpc.!dion. I povid.d for by Ssrion l70o of lta <br />t ho. C.d., for rh. rE fo.rl1.E of dE elt for sti.h lhe Demir ir isslcd <br />_l hovc and will nlinrain work r' conFnsrlion imumrcc. as eqxid, by SNt io. lr00 ol fi. Labor Cod.. lor rhc pcrlormc ol <br />lhc $ort for wnich lnh lcrmn is isscd- My workctr coEl,cnrori.n insu.mc carhr rd B,lty numb.r uc: <br />PolicyNuD6..: Erpir!! <br />-l <br />enifrthar in lic rcrfotmM of llrc worl for whi.h lhis pdmil is issucd.l sh.ll ml cmployrnylcMtr in onyronmr <br />s 0s lo b..onr srbhcl ro rhc rcr*cc mnpc.erion h* ot ClliloDia, $d aglE fiar if I sh.uld tEcorE iuhjccl lo rte <br />workcm ool,cndion omvjsions of setioo lT00 6l rhc t$or Gn . l slEll fonhwlh 6nplr wirh rho* novhio8 . <br />WARNINC: Flilm b sw wort R o"pcnsslion .ov@gc ii unbwtul. .nd rhdl subFt an.mployrr lo aimiml p.Mhics.nd <br />.ivil fincs !p lo onc fiundrcn lhous d dollm (S100.000), in rddirion lo llE.osl oaconp.nsalion. drmg$ as pmvidcd for llE <br />S.crlon 30?6 of rhc L{tEr Codc, inrost $d rnomy's fes. <br />D.ler ADpliml: <br />CONSIA!]Cru}I{IEIDINGIGEICT <br />I hcrcby arrm uadcqemlry ot pciury lld lhrcE h a .oneerio. Ieodir8 aScmy ror rh. Fnommc of rnc wort for whicn thh FJmh b <br />hsucd (Se 1097. Cit. C.). <br />AITLICANLIIEO.AAAUON <br />I h.El,y omn undcr t.n,lly of!..jury onc ofrh. followinS delrario rl <br />Dcmliltu. Pfnir* Ashc{os Noln rrion Fcdcr,l Reguhtio!\ l'Int.{). Pad6) <br />-Rcquir.d <br />txrlcr of Nolifiorbn <br />_l ccdify filt rhc fcderal rcSukrions ESadinS ashcsros Emvd m mr ,prliabk lo this pDjcd. <br />_l ..nity rhat I h& rod rhh lpplkaridn urd starc rhar rhc lbvc informrion is cor.d. I agrc lo ootly *irh lll Ciry and Count, <br />ordinaeer and Slarc Li*s Ellri.s to huilding .onsltucrion, an hcEby aurhorirc EFr*nrali!.s ol rfiis Cny and Counry ro cnr6 ll'on iE <br />abor mnriorcd pDrcny for inslerion IuIxEs <br />Appllcani or &€nl Sisnotum <br />P.mltE qn. (D.lnl):_ <br />'iWlgil,Z <br />ID/SIG. <br />uglsEDiaNlxacraf, <br />DtrCIABTIION <br />I hcrcbr rl'ltm uMcr r..rlrt ol pcrjury rhm l N li.t.{d und.r I&,viri,)n of Chapr& 9 (.o xmRing snh S..rim 70([) ol Divisidr :] <br />of lhr Bu:i'rc\\ xnd PmtDssnnN Codc, dd my license is in tlll Iirrcc !d.l.lr.r <br />Li.cns. Cla$:-Li.cnic Nuib.i: <br />frsre Conlmror <br />troddl AddE r: <br />- <br />Water Service <br />Meter Release