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PLUMBING.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARATION
<br />I h.rby affim ltdd pcMlry ofp.dury $d I @ q.opt 8bo rh. aontn.loB Lic.n* l-av for thc following r@$. (Sd 70ll 5
<br />Auin*s 0ld lbi.$ion Cod.) Ary Cily or Coudy which r.quiE! tr Fmil lo @n ltucl alld, iepreE, &mlirh or rqun any
<br />nructurc, prior ro ilr isMq als rquiB rhc arplic.nr lor suct p.mn ro illc a lieod rd.lmr lhd h. or rhc ir li..tu.d nwd{
<br />b lh. pmvhiotri oftl* Conr@rofr Liccn*d L.w {Ch.prs c, Codtueins wnh S*lioo 7000 ofDirisio. I ofllE Blrircr! a.d
<br />Pofc$ioB Codr) or rhar lr or !h. n q.npi rh.Gtom ad 0E hci! for rh. sll.ld.x.dption. Any rhl.lion ofs.6ion 7011.5 lry lny
<br />applio turp.mi bjerrth..pplicdntlo5civilp.oallyolmtmEfir.fivrhundr.ddoll&s(5500)
<br />-1,ss
<br />otuofrn pioD. y. orny.nolorE3 wnh was6d rh.n sb oftpo8diorL will& llEwori!,n !ntudcnml
<br />i,kitdcd or ofl.Gd lbr EL (sc 7041. Bui.d ed PofBiom Cod.: TlE co ndol. LicrE Lae &d el apply to to owF 6f
<br />ln r,6n6ty wh.t ilrte or trlpmE th6sl\ tld r &6 $ch sbd{ himq.lfor lEelfor fislgh hi! 6. hs om.roloy.d,
<br />povid.d tnlt tuh inpoElEn| E mi i .,i.d o.oi*cl6. sk I[ now, (tF t{iltir{ or inpoktud ii $B wnhi. orc tar
<br />ofonFklb{ rlE O}tur Buitld will ltsE ihc h!d.n ofnftvn e rlEr h. or .h. dd ml hild or irpmk dE pmp6ty irr tE pu.txE of
<br />_1. as6w.o.f$. p6fd,. am.ftluriv.lymdmring *irh lic.rcd conlmcloB t. o[drucl th. Droj<r (56.7fi4. Batm
<br />and PmEsi,n Cod.r 'rhc Conr&rof s l-ic.ns Lls dos mr lnplyto anolMoftorcny{ts buil&or imDov.r th(6l\
<br />.nd wl'o @rrods tor $ch pmFk wilh a co Edo,t.) lico*d puND, to rh. ContEclor's Lic.tre Law)
<br />-l
<br />m ci.mpt rnd.r Sdrior-. a. & P.C. f.r rhi.r .@tr
<br />Dr(.: oft.i:
<br />]IESAEErcAMTEIIAIIO!
<br />I&qLAEAuON
<br />I h.r.by .fim utd.r ,..!lry otFjury oi. oith. hllowinr rh.bEtioN:
<br />lhavca.dqill nuinr.innCerlificrr.ofcoNenrro s.lllnsure hr $ork.s' conrpensarion, 0s novided hrbySdlnrn 1700olrh(
<br />Ijhor Code, lbr rhe n ln,m.nce o llhc solt for which rhc ,ermir ls hsucd.
<br />I havernd+,illmaintarnsorkeri co'nncnsarnn ihsrrancc- as rc+'tod6rs.c(imlT0lrolrhet,ib.rCodc,ntrihcrrn,nn.nccof
<br />lu
<br />pemn ir os.n Mywortc6 crnnFnMro rnsurm. 6nicr ad policy numb{ lre
<br />r^l:r.r4(t La j-w\
<br />-rJr.,r.lC.
<br />_I c.diryrh.r io lh. p.rformE ofth.*olt for ehich rhi* r.mn ae i6$sl, I ll8llmr colliy lny p.Nn in rny nBnrcr
<br />rc N to h.oft sbFr lo lhc ,o d om,'ttrerion lrws ol Califoni& and 6E@ thd if I shuld h.sm subj.tl lo rh.
<br />wo*e6' strrre{lion pmlisioB of Sdrioo 3?00 .f rhc LrtDr Cod.. I ilull. tonhwilh smply with llsF ltmvisioB
<br />WARNINC: [r,lur. to scu. work.F 6r{rnkrio. svda. ir unlawtuL .nd $.ll flnFl sn mploFr ro 6miml Emllis and
<br />olcomp.trslon. dam*.s as frevidd t-or rh.
<br />llclatAuaN
<br />I heEby.mrm unds pclElty o tFrjlry lhlr I am liccntn utrd6 pn,lNion olChtrrn 9{commncinE wirh 56lhn 7000)ofDivs!,n l
<br />of rh. Bu.in*s and Pmlcsio.sCod., ud mylicctr. is in tull anR on cfi6lg
<br />llotT5-mg *.",_ '**-H (orr.1"t%a
<br />cQNnIBUCUOlJ.titrDlN{i.&C[lCI
<br />I h.Ehy aflj,nr rndc. FMlry.f l.lury rld rh.r. ii i.onsru.rlon Lndi.g.scrcy fo. th€ r.rfomncc olrhe work tu which (hs P.mnr 6
<br />hsuen (Se.3097, Civ C ).
<br />ASg,tcAlLIUiCt AMll9N
<br />I h6.b, a0id rnd.r Fnnlry oI t.rjury on. olrh. folkrwinS del.r.rioni
<br />DcnnlitionPenrns-Asb.stGNoliliclln'n ldcrrl R.Buhlions('l |c40, Pad6)
<br />RequiEd L.trd olNonfi olion
<br />-l
<br />ceniry lhat rh. f.dcral ceullliom a!&ding a$.!t$ Emhl on mt dpl'licahl. lo lhis prcj.d.
<br />rnfomrion is coF.cl I lsre lo comply wlh all Cily i l County
<br />.bo\r dmr6n d pmr.ny tu inrF.rio.
<br />Appllc.nl or Agetrl Slgnrlur.:
<br />.frhrC v md Counrvh cnra !d'ntlE
<br />ilov | 5 z0|s
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Building Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarifier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Piping
<br />Roof Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOUSPA
<br />Ptrap/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 />Back Flow Device
<br />Rough Plumbing
<br />Final Gas Test
<br />Meter Release
<br />FINAL u?.01$inKq
<br />Notes, Remarks, Etc
<br />cMl fin.r u,' h oN hu,imd rh.us dollan (tl0{.00o1
<br />s4ridn 1076 ol rh. lih6r cod.. intd ,nd .nrEy'! f*s.
<br />,",.,1{0vl52llr0
<br />4- r,
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