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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNI,R BUILDTiR DEt,CARA'TION
<br />I hcrchy.fllrn u cr Fnrlry {,f pcljury lhnr I am crenDr liom rhc G ra.ttrJ Lkcnsc Lrw li,r rhc folhqing r.i\ (SN.7l:115
<br />lJusinc$ rnd Profcsnr C(xtc) Atry Ciry or O)utrry shith r.ttuirc{ r ,oni t, .oi{tu.r, rlr.r. inwort. 4cnmli\h o. rcpat 3ny
<br />{ru.rurc, priu h its N{rncc. aho Lnutc\rhc rpplicrtrr nr \d(h n rnrir ro filcn silncd (nErmnl rhar ltor shc N li..n\cd Pusurni
<br />h rhc pr.vili{nN or th. Contmrols l-icctrscd lns lchl0cr 9. Commcncir! {irh sr.rt,n rfiD ol Divhion I of rhc Bu\i[c\s dnd
<br />Pr.ri\\n,n\ Codcr.'rhsr hcorshc i\cxcmrrrhcrclronrmd rh.hrsn n,lhcallcgrdcxctrr nnr. AnyvioltrtionofSftihnr03l5hyrtry
<br />rnfl'\,J{{ l'{ Jnsm .uhtc!tsrhc iml'.rrth,r.1\'l|cnJl)nIa, nn rrhJtrlrchutrJ(tlJ,,rlrr.'!<rvr'
<br />I.r\ owkrorrhcpnrr^-.nr.ornry.mpl{'yccswir[w!sc\rslhcir{,ld.o.r trs0rmn. willno rhc voii ddcdmrmia{
<br />inrc.atorofic'.dhrslc(S(7(}l-{.Bu(inc$nndFYoLssioniCodc:lh.Conrrc(,\Li...\ctisdo.snor0pplyr.rnosk'of
<br />rhc nn{rny $ho hrikls o! irrrDrcs rh.rN.. rxl *ho docs \xch Nod hnn\(lfor hcr$lf.r rhrcugir ti\ or hcr own cnrll.yccs,
<br />pn,vnhd rhlr \rch n$olcmnisrE nori cndLrd orolilrln n, {lc ll tx'wc\..rh.huiklnEorin{rottr.r N wkl wirhiion. )cr
<br />ol'conl|lkri('n. lhc O$ncr BliUcr sillhr\t rlt bunlcn of F'virE llaf hc or shc did mr huiH or iq,nrc thc !^]Fny fot 11* IurJr,s ol
<br />-1.
<br />&s otrncr of rnc prol)clry. af,.rclusivcl,cont,clingwnh liccn*d co mcloF lo connrucr llE Fojccl (S(. ?044. Blsin6s
<br />,rt Brfsio( Codc: Thc Conr.dols Liccnsc Ij* dEi flol aPrrly ro & oen r of prcp.ny who builds or iaprov.s rhercon.
<br />and who conlEcrs for sch ptDi$t eirh . co.|d.lo(3) !...sd pumanl Io tlt conln roa. Lixnr r,w)
<br />a & PC nrrhi\ rcnvnr
<br />DEII.ATAIION
<br />I lrcEb, .lfirn und.r pcn.lry of Fjury o.. of lhc followinS dehrulions:
<br />-lhrvcan(lwiUnuinrli.aQifi.dcotconsctrrt,sclilNurcr(trworkcsconi|*n\arion,{providcJlhrhySccrn,nlTmolrhclahtr (r)dc. Ior rhc n nbrro!.c ol rhc sork f{r rhich rh. Frrnir ii i\nrci
<br />-l
<br />halc anrl will roi.tain wort6 conpensatiotr ins!6ncc. as rcqlncd by Sccrion 3?00 of ih. tjbor Codc. lot th. Frfo]rure of
<br />rh. {o& lor whth lhis prmil is issEd. My sortcc conqsrslior iosuec cdtr 8In Polky numhd u.:
<br />PoltyNu!$.r: Fxp
<br />ll&6tifyrh in rhc pdformmc of rnc wort for which rnis lermir is hsued. I shall nor cq,loy lny pcison in .ny Mno
<br />$ $ ro b€lm .uii(l ro lh. sort R'om!.nslrion laws of Glifomi.. .rd alrE lh.r il I slnuld hccom subitl ro llx
<br />vorkda.oqEn$ti.nDmvkionsofs.rtiorlT00oflhcktorCodc.lshall.fonhwilhmnplywilhtho*!'roiiiions.
<br />WARNINC: Fnilurc to $curc *or*qs ..4tnsrnrn svcmgc is unh*tu|. and shall \ubj.cr d cnPloycr ro rinrinal lEnahics 3.d
<br />civil in s ut ro.nc hundrcd lhousatul dolle$ (Sloo,ux)), in {ddnion lo rtu.on olconFnsrio.. drmSls as rmidcd for rhc
<br />q ydn tco
<br />DA:Ir'AAIION
<br />I hcrciy nnrn{lcrpcnalryornlurylhitI!mliccncdundcrprcvisb.orchnprcr9(c.mmncin8wiltSsri,n?uI))olDirisionI
<br />of rlr Busirc$ otrd Prcri$ions Adq md my li.dn{ i{ h full nncc and cficci
<br />co!flf,ucuaN!ENllluclclNlt
<br />I hcrchy afiid !nd.r Fraxt ol pcrjury rn r thcrc h a .onslrucrion lc.din8 ie.n , ror rhc [{rfornErc ot rrE sork for whi.h rht ncmn is
<br />ksucd lsc. 3097. cir. c.)
<br /> PPLICANT DECI ARA'I'I{TN
<br />I hcdy rnim urdcr pcnalry or !.ijfiy onc.frhc ftllowin8 dcclarnrions:
<br />Dcnolilnrn Pctrnirs Ashcsro\ Norifi.ntk,n Fcdcnl R.Sulilio.s (rirh 40, Pan6)
<br />-Rcqrirci
<br />lr(.r of Ndill.:ni.n
<br />I ccn ily rh0l rhc ltdcrrl rc-subl ions rclrdins asb.N.\ rcmuvrl m n r atdicahk lo rhn pn,Nr.
<br />I ccnify that I nolc rcrd rhir apnli.arion dt strlc rhnr rhc atnr intonurt,. is corm'. LS'N lo cory)ly wilh all Cnyand (t,rnry
<br />ordmrNcs und Srnre lrws shrins ro hxildnr! con{rucLon, ed hcrcby rul hoiizc rcprcscnr,riv.s.frhis Ciry.nd G,hryro c.r.r uF n rh.
<br />ovc mbtiomd tml,cfly for in
<br />AtDlionl or Allenl Si8mlure
<br />PemiIF mmelprlnt)
<br />q a
<br />UNDER GROUND
<br />Water-Under lloor
<br />Gas-Underfloor
<br />Buildino Sewer
<br />Area,/Storm Drain
<br />lnterceptor/ Clarilier
<br />Waste & Vent
<br />Water Pipino
<br />Gas Pipinq
<br />Roof Drain
<br />Tub/Shower Test
<br />Rouqh Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />lr/ain Drain/Pool Pipinq
<br />Fill Line/Back Flow
<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 Plumbing
<br />Final Gas Test
<br />Meter Release
<br />FINAL ,b/drA -aErl(jrrrld',
<br />Notes, Remarks, Etc vu
<br />Waste & Vent
<br />TOP OUT
<br />O.r" 0
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