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APPROVALS DATE ID/SIG.COMMENTS OWNIIT BU! I,DF,R DTJL('A RA]'ION
<br />I hcrchy ninnr untur |l.mlr, r,r t'crjury thln I unr.$nrnl lion, rhc Coitr.ror\' t,iccnsc li$ ln' rhc n,lbwirE L_aqr (Scc 70.ll 5
<br />Ru\inc\s rnd Pnrfcssi.r Codc) AnyCit!orCou ryshi.h rcqun.s 0 Pcnnir ro.ondtu.r..X.r, nnProrc. dcnx,li\h.r tl'n ry
<br />sru.rurc. |nirtrk, irs i\surn.c. nln, roqrircs rhc ipnlrr lirr \uchI.nnirt,lilcn\r8trcd {lrcnrnr rhxrhcordt liccnsci !trrsuor
<br />t, rhc lhvrr 1of rhc Conrrr.kn \ l-iccn\cd Lis lchrPrct 9. CoDn Ni',3 sir[ Sc.ton 7(XD of Divi\ioi -] ofrhx I]usi c\\ rnd
<br />Prntx\ion\(-t clorrharl..orthc i\cxcmpr rlNrcironrandrtu hr\i\ lor rhc llcgcd cxcmari.n ,^nyvn,LrionofSccriurT0ll 5hyrny
<br />rmlicr turr$nnir\ubJL\r\rhc!I,f1i$trrn'acl!ilpdrlryofnorNtrcrhrniivchundrcdJolld^(S5(X))
<br />-1.
<br />s o*mr of lhc popcny. or oy cinplort s wilh *.g.s &r lhcir $h onFn$lion, *i[ do tlE sr* and da stsurm k mr
<br />Inrcid.d 01 oftnd lor $t (Se.7044. B8ift$ sd Pbfersions Cod.: Tnc Co.udorr Lic.nsc I,l* .Lei @t .pplv lo u o\rM of
<br />rhcpsFny *h, tuilti or intmB thcM.0rd wt .ioe! sh eort hiFsclfor hsrtfot lhrcuE,l hls or ltr oln cnplove!.
<br />prcvided lnd sEh inprevmnu e rcl i.rcnd.d dof.Ed lor sk. If. hoEE tlE t{ildii8 d inprDvlEi h sU wihi. om )4,
<br />of odphlbtr rlE O*Gr Btrildd will h,s tlE bonlsr of FwinS rlgl lE or dE dil Dl taih d itpmt Ut lolEly for 0E pltloE of
<br />1.6 owrcr of rh. Impenr. tmcxclusivcly contturins qilh lkcnsd.onllldoslo on$od rhc lmj{l (Ss 7044,8tr\irs
<br />ad troas\i, Cod.r Th. Conlrocrors Lic.n* L.w dGs nor,tplylo an o*ner oftm!.ny wno builds or idPovcs rhctmn
<br />snd who contflch for soch ltuj<rs wnh a ConLacto(O lt.r$d plrM ro lhc Conlrelols Ltcns L!*)
<br />lrn'.\. ,ri 0 L!.r Sr.r,r, .8.!l'( l'rrlrir'.,\,,
<br />Dor.:
<br />TOESEII.COMPINTAIA!
<br />DECLATAIION
<br />I hcr.by lfatrm undci peoalry orFiury onc ofln fouowin8 dekfrlioB:
<br />I hdrc rktwill nrtrr!ir r Ccnifi.rrc ol ConscN t) S.ll.lr{trc lin so'kc^ .otrrlf,trsilnn1. rs nmvidcd tur hy Sccrion 37U)ol'rhc
<br />LihrCo c, f{tr rhc Frlnrnrnccollhc sork ftn which rhc l.nnn i\ issucd
<br />-l t!v. rfld *ill minloin *orkcre'cooFns ion insEtuc. as r{uird by Selhn 3?m of thc Llbor Co<,e. for lh. pc.fodftc of
<br />fic mrt ftr vhtn lhb Dcnit iq issuad. My wort.B omp.nsarion insurec cdi.r .nd Policy numbet @:
<br />S'rare €v .,\
<br />I R 'r))-(r2at(
<br />-l
<br />cenity rhar in ih. p.rlorm!rc oflh. worl f.t whth rhis F mn k isslcd. l ihuu @r cnpk y $v rc6on in rnv ronmr
<br />s !s ro b.om subrc.l lo lhc q,Adi mnpcnelbn ltrws of Calirohi!. atd {rE tnd if I should b.c.m subjdl io llE
<br />w6rkc( onpcnsalion t Dvisions of Scrrio. lT0O ol rhc t$or C.de, l slblt. fonheith mq,ly Pnh llss povisions..
<br />\eni(r l{)r6 0rrh.lIlly{ix!. i' .rr{ rDJ attncv's,.c\
<br />,r",6-(-rt n,,u*,,-PltP >e
<br />-
<br />LlcfNsFn coNTn-A( ToR
<br />DECLINAIION
<br />I hcrcbr 0m n udcr t nllry or r.rjury rhd l 0m lieN,l undct Drovtioo .r Chnprcr 9 (connmocins snh s(tior TOtx) oI l )ivi\k,. l
<br />of rhc Burin.ssand Pofc$iorrsc('dc. ad nryli..n* is in hll6rcc atdctt(r'
<br />B qPlS12-
<br />-( -
<br />caaElB!]cll0N.L[NDllli-&c[Nl1
<br />I hcEby aiinm lndcr rsndlry of pcrjlry lhal rhcrc h a .onndcrion lcndine "8cmy for thc I'crfomnc. of lh. wort for shich rhh Fnrh is
<br />ttrued (Scc.109?.Civ. C ).
<br />AffI,Ic1 ILDESAAAfIOIi
<br />I llnhyifiimu cr prnrhy orpcrjury.trc oflhc following dNhrrrion\:
<br />Dcmolirn,n P.i,nits- sh.nos Nolificlrio. Fcd.dlR.Sulalioisllirlc.l0- l'an6)
<br />Rcqun d lxrrcrof Nolili.ari,n
<br />-lccniiy
<br />rlu( rhc r.dcrrl mguhrioN rcrnrJirs nsh.(o\ rcnnnrlrr. nor rrnric$l o rhn nr+cr
<br />ft -.niryrru r r',vc,cu rrri\ ilpliclri.nNd (srcrhar rhc oh.!c inrnnsrn i\ cotrccl I rArccloconrdysirhrllCilytnd cou ry
<br />odin!nccsrldSrarclis\fthrintrobtrildinrconslrucriqr- ihcttyrtrlrriz.t.!r.sctrr3rirt\{,rrhi\cirydndcrounrvroctrrcru|r rrr
<br />,tiNr nrtrrion.d pmp.riy for inspcclion $[ii- rz_Applie orA8enlSiAnuluB:(-(-(>
<br />UNDEB GROUND
<br />Waste & Vent
<br />Water-Under Iloor
<br />Gas-Underfloor
<br />Buildino Sewer
<br />Area/Storm Drain
<br />I nterceptor/ Clarif ier
<br />Waste & Vent
<br />Water Pipinq
<br />Gas Pipinq
<br />Roof Drain
<br />Tub/Shower Test
<br />Rouoh Water Healer
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Main Drain/Pool Piping
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Lrne
<br />Miscellaneous
<br />Gas Service
<br />Water Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />Rouqh Plumbinq
<br />Final Gas Test
<br />Meter Release
<br />FINAL 9a/rg ,c k2r6.
<br />Notes, Remarks, Etc.
<br />PLUMBING-INSPECTOR RECORD
<br />TOP OUT
<br />""-"**."o*r, Phi\liF
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