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PLUMBING.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />UNDER GHOUND I
<br />Waste & Vent 7/nilt,4 Wrt)
<br />Water-Under floor
<br />Gas-Underfloor
<br />Buildino Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Pipino
<br />Rool Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />P-trap/Drain Line
<br />Main 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 />Rough Plumbing t)lx/lf,.+&u
<br />Final Gas Test
<br />Meter Release I
<br />FINAL 1/t//4
<br />Notes, Remarks, Etc.
<br />to /,ttt /t ? 1la,{r-z our,,.J 4/, < I 't tL-I U
<br />OWNI]R BUII-D[R DILCARATION
<br />I k.cb, alnnn u dn I,.o,lly {,f p.rjury rh l ur cxcnll)r riom rhc (1}nra.lm Liccns taw {or lhc lollowins r.r$ (Scc 70.11 5
<br />Bu\nts snd Pnnt$i (idd) Any Cir, or C6u.ry *hich Equt$ a pcnnir ro cond'ut. rlrcr. idpiovc, dcmnish .r 'rtrn r y
<br />drucrurc. Prior b ns i\sudcc, rlvr rcqutcs rh. lplliclnr i.r such pcirnrt r{' ljlc a siErrd nrcaEnr rhat hcor \hc i! l'.cnscd Purul.r
<br />lo rhc [ovisnA orrlt Conracl( \ Li.cncd Llr (Chaptc! 9. Connrrcins wirh Sccrion ?un ol Division ] orrh. Br\ir$\ rn,l
<br />Pmlc$i,'ns(lnlc)orrhnt h.orrh. iscxempi rhcrcfrom n rhchlsisntrrhcrll.lcdcktr1lrion,Anyvioltrri,inofSstbnTl)-1l5byriy
<br />npllnnr ror a l}.rnril subjlcls rhc {plic0nt Io , (ivil lcnrlry or mt nnc lh rivc hundrcd dollars (3500)
<br />-l.rsorncr.llhcpnJr.ny.(trnrycnDloyccssirhwr[csurthciry)lcomp$!ion.willddrhc{.r*u
<br />rtr(n{!Ei\ nor
<br />inrcndd or oUtrc.l tbr ele (S1r.7U14. Bu\i'rcs Md Profcsn Codc rh.Grirucr.r'sl-icc.selrwdocs.olJlplyrortro*ncrol
<br />rhc pn)pcny qk, toild(.r ir0R,ls rthron. rd $h' dms skh sork hinlrcll.r h.sclfor rhiduEh hh or hcr.sn cnl,lo!_ccs.
<br />lr.vi(lcd rhar skh impftvcnrnls c no I inrcn.lcd ff oii:^d h.\rh lt huscrs. rhc builliB or irr(ittum i\ sld wirhinonc rur
<br />ol con{'trin, lhc Owtrs Burlds sill hrvc lhc turddn ofprovnr! rhd Iro.lhd did nor hui or nvmrc thc lmpdy for rh puqB{ ol'
<br />-1.
<br />!s opncr of rh. pmp6ry, ,n .x.lusjvcly mrtD.ring wirh lienqd .o.rracroF ro con$rud ihe llo.id {S(. ?044. Busifts
<br />.nd hoe.si, C4dcr ThcContruror's Lic.ns tiu dcs ml.pplyro s owns olprotEnywno blildr 6r impmvcslh.mn.
<br />lnd eho snlrmis ior such polccrs sirh . Cnimcro(, liccnsd ,u6u ro rhc C4nrucrois Lk.ns tr*}.
<br />I rn.x. rt, xid.r Sc io
<br />&OBf,!X5:CqMIETAIIQ!
<br />DES.AAAIIIIN
<br />I h.rcby rftuo und.. Fnaly ol pFjlry orc of the foUowi.g dcchrrlionsl
<br />, ha\t.trd willnrirnr dCcnlliurcolCon\.irhSclfln\rrclortrorlcrr(n!.n\ n ,.\ tnridcdnrbrScclotr:t7(x)ofrhc
<br />Lrhitr Cod., tur rhc FnnnnMcc or ihc sork ntr *hi.h thc p.nir i! i\\!cJ
<br />$hlvc and will n.intoin mrlc6 onpcnsllion inslarc., as EquiFd by Ser ion 3?00 of $c t bor C.dc. for tlc ,cd()m@ o,
<br />*ork for *hich this pcrmil is h$€d. My *ort.s comp.osarioo insurana cmier od policy nuhbcr N:
<br />AD GoR('\lz lulb
<br />-l
<br />crlify lhd in thc pcraomore of thc eork for wnth lhis Frmh is issucd.l sh.ll ml cmployNy Fcmn
<br />T_
<br />m iq ro bLsm subj.cr rd rhc mrkqc conF.srion laws ol Calitodi!. ed d!,e ihar if I rhould tr.om suhjccl lo rh.
<br />mrkc6 @npcn$lio. tiovntonr of Seri.n l70O ot rlr tjtn. tuc. I rtEll t nh*nh millty wirh rho$ [ovisions..
<br />WARNINC: F.ilurc to RUrc workcs' .omp.nsation cormEc n unhwtul. atrd sholl suhjecl u cmploFr to sidinll lrtuhics and
<br />civil finrs up ro ore hxndrd lhousand doll.is (tlm.uD), in.ddnion lo rh..o{ ofcompcnsrion. dom8ls.s Imlilcd lor rh.
<br />Dl.:ct ,\ta\,t1(,N
<br />I hcEby,ffifln undcr Jlc.lhyolIcUUry lhr I am lienan utrdcr IonionofChaprcr I kun'tmins sirh sccrb. TGl0) orDivi\trn:l
<br />ol rhc Bu\imsand PrefcssionsCodc. mi my !i.M\c is ir fullftr.c ! clti.l
<br />B lzzzd-fiw
<br />qONEIf,I]CIITNIENDIIIGIIiENCI
<br />Ih.Ebylllimu.rpcn.llyoaFjlrytlErtlErcta@nsficrbnh.din8sgcmyforthcFrf()lmmofri.w*fo.shf,hthisFn b
<br />ksucd (Se. 3097, Civ, C,).
<br />ATILICAII.DEC!,AAAIION
<br />I hd$, atrm ! ndc, ,e.alr, of ncrjury on. ot fic following d.rlearioos:
<br />[k]mlirion P(mih-Asbcsros Noria@rion Fc{€nl Rc8ulations Onb,O, Pan6)
<br />-Rcquircd
<br />l.nsrof Norifi calio.
<br />I .cnia, lh,r $. fcdcr.l EBUt0'i.ns ESardnr8 asb.nos r.fr,vd arc nor lpIltubh b rhis pmirr.
<br />-l
<br />.cnify rhor I havc rcod rhh aprikarion a.d sl.rc rh,t rhe rlc informrion is comd I .8re h onply wirh dll Ciry and Counry
<br />ordienccs lnd Srare lj$ elarina to bnildi.s c.n{rErio.. dt'd tcrctylurh ?c rcFc*.rdivcs of inh Cn, ud counry ro .nrc uPn rtE
<br />lhovc nrtrrioncd pmpcny nn in\!.crion Ftrrlxh6.
<br />.{pplicanl or Aaml SianeiuE:-")I
<br />IIIII
<br />D&/
<br />POOL/SPA
<br />Back Flow Device
<br />L.nd$ s Nrm:
<br />-
<br />t ndcit AddB.:
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