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PLUMBING-INSPECTOR RECORD <br />APPROVALS DATE IDiSIG.OWNER I'U!LDI'T DI]I-CAXA'IION <br />I hcrcby .flirfl und$ p.ndlry ()r l.rjurt rh, I m cx.mir from rhc C.ntlrt,J Li.cnsc trw tu E rbllo{i,r8 tcawn lsc.7031 5 <br />Bu\nB\s n Pdcst'n Code): Any Cily or Cornr, which rcqurc( r fqflit ro mn(ruct. rllcr. iorn*q d.rmlnh ur RI'Jn My <br />sru.nrc. prsr kr ir\ ns[kc,11\o r.qxiru\rh. rlplic]d tur \uch p(nnirt,lllc a \ig drlsdcrmir rh r h.or shc G li.cn*d tturnanr <br />tJ rh( provni(r\ ol lh. Conilr.ktr s l,icensed li* (Cnlrrcr 9. (tnrmncins trirh Sccri{,n 7{xlo or Dilknrn I or rh. BuriNrs lnd <br />Pmrcsri,,.\ Cod.) or th h.urshc i\.r.nfr lhcrcriodhd rhc htr\is tur rh. allc8.d crcmfl nrn An, viohlionofSccli.n 70315 byrny <br />l'plicad tuap.Itri subjLrrs lh. ipplicn lo r.irilpculryDrnor.xnc m llrc hundrcd doll$ (5500). <br />-1. <br />us osncr ol rhc rftIrcny. or fry cnployei qilh *uscs as thcn sb .onqEnsdion. will do tlE wok 3,rl rlE slBha is ml <br />inlclxlol or on rcd lor elc (5(.7044, Btrsinc$ 6d Profcrsions Codq Thc Cnntturor s Lk nr kw &Es nol epply to an owtr of <br />rl* ImFny *,[ tuildr or inpmm tlErsn, !d who des Mn wl* hins.lf or hcMlf or lhmugh his tr h.r o*t cnrrloyccs. <br />Pmrilcd lhal slch tqmEmnts e ml hlcndi orofcrcd for slc. It thMrci th. huildinB or idqfttmll| n sE snhin oE Jtd <br />ofonpklion. th. Own$ BuitL. uill hlE rlf hor.Ln orprbvidg tld lE o, sh. did mt bxiu or ilpmw thc pmlEiy for * plrlDs of <br />_1. {i owncr of rhc repcny, an.xcl8ivcly coni.a.rin8 wirh liccnsd.o.rrcro6'o mflsdcl ltr t mFl (S8.7014. Burift$ <br />rd EDltsshn Codcr 1'h. Conlmtol s Liccnrc Lsw docs nor 0l,Ily to an owncr of pmpcfly who builds or imrovcs th.ren. <br />{nd $ho @.rmh for slch pmj<ls wirh a Conrmcro(9 li.ctrEd lrununt lo rhc CoorEcrols Licc.se t w) <br />I nrcrrnlpr und.r S.crn,n- B. & P C. air rhh rcd$n <br />WORKFILS' COITPFNSATION <br />DECLABAII!}N <br />I tcrcby affirm undcr Fnoll, of psjury on. of thc tollopin8 dehrolions: <br />-lholcmdwilln{inr.inaCcnirE <br />colconc ro Sclf.lmurc i{tr wo sr co'nrEnerion. as [ovidcdtnbySccrion]?00orrh. <br />tahn Codc. for rh. r. nrro..c olrhe work lor which rhc p.rnrir is ir\u.d. <br />_l hlE lnd qill rointein eo cis conpe Barion insumr.c. as cqltcd b, S.crion 3700 ol rhe tjbor Codc. tor rh. Ffolllffi. of <br />lhc work for which lhn p.mit is issucd. My vort6' onFnslrion insurarc c&icr dd polic, nuntcr @: <br />Q?-tra(4 <br />-l.cnifyrhll <br />i. rhc Friormrcc of rhc so* ao, *hich rhi\ F nn is issncd.l 1huU nor coploy,nyp.rhn in trny <br />'mnmr$ 0s ro trcom subFLr ro rhc uorkdc mmr.n.alion h*s of Califooi|. and .gEc thar if I sfiould bccom subjE o rh. <br />mrtcB' conp.n\.rn . povnions of Sf ion 1700 oa rhc Libo. Cd.. I shlll lonnNid onpl, sith rtFs pmvisions.. <br />WAININC: fiilurc to sdrc Forke6' compcnsalion covcroE n unhwtul, and shrl slbjcd an mtbrci ro cifrinnl lfMhi.s rd <br />civil finc\ u! ro on. h!.drcd th.usa.d dollaB (Sloo.o(x)), in lddition ro rhc.osl ol.ompcmarion. d,mB.s rs tmvidcd lor rlE <br />,",",-'t\ao\tg { <br />ut!tr\!.!r.&! <br />I hcrchy!fltn undcr lrcnoh,oipcrjury th l am lietr*n undcr Eovision ofChaprcr 9 (comm.cinE *irh Sr.'rbn 7(x[) orDivkion ] <br />of rhc Ausimss n.d Pof.ssions Codc. Md ny liccn$ n in rull forc3al cficcl <br />toll4 ) k <br />III:LrcANLIECIJ.BAIIO! <br />I hcn:tyJJlnnrundcr lfnalry of F{jur} onc ollhc follosirgdcclon nnr: <br />lxmolnion Pc nir$Ash.i.s Norificrhon Fcdcral R.EUlxrions ('Iirlc-10. PM6) <br />Rcquircd krrcr ol Notifi Larirn <br />-l <br />ccdilyIhar rhc ltdcrol rcsuh r ions rcsordins artEnos rcnnvllorc.ol lrplic le l. rhhI,oiccr <br />.t <br />1_l (cdil,rhr I hovc rcad rhtr,np!E n,n and qarcrhd rhcdnvc inlornurt,n tcom.L Lgre ro.onDly wirh sll Cnr and County <br />ordinaDcc\ lnd Srric I!t\ rcld olrhi\ Cny md Counrylo cmcr up.n rrE <br />lhovc nrntiomd !ro!.rly for *]4_l'6 <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 Pi ping <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Healer <br />POOL/SPA <br />Ptrap/Drain Line <br />Main Drain/Pool Pipinq <br />Pool HeateriGas Line <br />Miscellaneous <br />Gas Service <br />Lawn Sprinkler <br />Sanitary Sewer/Cap <br />Back Flow Device <br />Rough Plumbinq 1/4/lq Agb <br />Final Gas Test <br />Meter Release <br />FINAL 4(tr / rz 5\11 <br />Notes, Remarks, Etc. <br />COMMENTS <br />Fill Line/Back Flow <br />Water Service <br />'<lr'"\tq <br />I hcEby affrm undcr Fn.hy of !.riury lhd lhe is ! oflnru.ion hnditrg sgcrcy for lh. pcrfotum€ ot lhc ft* lo. *r'kh lhir pcmn n <br />issu.d (Se. 1097. Civ. C.). <br />Lxndc' \ N'tu. <br />- <br />f------T------