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PLUMBING.INSPECTOR RECORD
<br />APPROVALS DATE IDiSIG.COMMENTS oWNER BT]II,DIR DI]I,C R I'IoN
<br />I herchy rl n und.r !.n.lry ol,'.!urr r[.] lmer.nDr fmn rh. (ontraclom'l.ic.nsc Las lo! rh. ftnh*ins r.s)n (scc70]15
<br />lrusinc$ rNl Ptulc$lor Codc) ny Ciry or ( ounly wlr.lr rcqtrtrcs ! ,!€irn l. {ndrucr, te( inrpro'r. d..bliih or toT.tr nny
<br />(rucruE, pnorro s rssu re. xlso.eqrtres rhr arplr t fitrsuchn rmrr ro lllc a ssftd { drh.nt rh.r htor she r lic.nsed pursrnt
<br />r' thc nnvhi,)ns olrtu anntrclo. s Lrcenscd Law (Ch,nrd 9, connmcnr-{ *ith Secrirnr 7(,0(r ol Divirion I .tl\c Bu$n6\ ntul
<br />I'Dlcsi,rns Code) or thil h.orshe N.xenDr lhcr€ior 0xl llE l"1qs lor rherll.s.alcxcmpr$n Any violtrhoiors.crk,n?0r15 hyrtry
<br />0r'r[c.N hr r ,*rrnir suh]ck rl[ rmh.nr lo a crul |)cnrlry . r noi nsrc rhir filc hn Mr.d doll.n ( $s00,.
<br />-1.
<br />os olE olrhe pmFny, or h, .nolorEs wnh was.s ., rhrt $1. @np.ns!lao,'. will d6 E {ot dd $. dndw i! tu'
<br />i .nd.d or olIcEd for slc lsd ?041, 8!{6 ed Pof.$ioG Cod.: l lE Conlncln i Lic.tr* llw .tE ml .pply lo d .*ftr 6l
<br />rh. toD.ny who build. or trnpoq tlEmn, and who do.s sch m* him!.lfor hc@lfot lhmush hh or h.r owo .npLy.6,
<br />,ovid.n thd fl.h imprn\Effi3 e mt id.i(H oro66td for sL. l( lbrda, rlE toidirB or i,rrownd t $ld si'tin orc F.olorpl.liol\ lh. O*r.r Buatlf {ill haE thc hurdd .fldviis tta| hc or shc did rct huild or inI'Nw $. pmpdy for llI puqrs ol
<br />_1. a 6wr of 0E pmraly. m cr.lueiv.ly co.lEcling wilh lic.a..d s 6cloB l. on{Ncl llE !mJ..l (Sc.7044, Bulim
<br />od Pofisio.Codc: ltuCo rlcroas Liccnsc L.w do.s nor onDly ro .n owncr o lnmD.ity who blildr or impFEs lhaon.
<br />rnd wh" 6,rmts for scn pmjEd! wirh . Co.Lero(s) lic.or.d lurM,rr b rh. Conrncloas ti<a€ ti,)
<br />I mcxcmDl und.. Sdlion ,8.&PC forrhn rc.mn.
<br />Drt : (rwr:
<br />WORI(ERS' COMPENSAIION
<br />DICIAf,AIIOB
<br />I hcrcby .flirm unds D.naky or!.oory om of rh. folloeinr drldtiotu:
<br />Ih.Eandwillmi.in!CdifEal.ofcon*ntloS.lf-lnsuEformrl.r'co6pdsrion,s,pmvi&dforbySetioi!70ootth.
<br />Lrh.r Cod., hr ih. pofoll1m. ofrh. wo* for rtich lh. p.mil ii ii{.d.
<br />_l h.r. lnl will mintoin worl.B com,E .aiion in{m&q d3 rqliEd by seron ]700 of rh. t2bor Cod.. aor lh. p..fotuc of
<br />rh. w6rk lor vhich rhh pcmir is Ls.d My workda NtrllEsllion ir$r@. ffi.r dnd Flicy numb.. 4:
<br />4tz 0t l.l
<br />-l
<br />ccniry rhat in th. pcrfo@N of rtE worL for which rhk pcmn is 6su.d. I .h!ll m{ .nploy aoy |,.Mn i. any notrEr
<br />s I ro b.oN subjet t. tn mrk6' compcMrio. law. ofcrlifomiia. ond .88 lhd if I should h..oft sbjel lo llt
<br />wo.td' omr,.ns{io. r,bvisioN olserion 1700 oflh. bl,r Cod., I sh.ll, fonhwilh comnly wilh thos pevhionr
<br />WARNING: IailoE to wur€ wod..6 onFrerion olcdsc h unL{tu|, and shaU subir ri mploy.r to Eiminal p€tuhis.nd
<br />civil llnB !p 16 6E hlodrcd thoraod dollaB ($100,000). i. addiridr ro $. co( ofsdp.nqtio,L &ffisca N pmvid.d for $.
<br />inGrcn and rtohey i fei
<br />lr /Y tx
<br />rl:(!aa.ul1
<br />I h@by aftm ndLr p.@lty.f p.dqy dEl I m lieEd und.r prcvsion of Ch.pt( g (smmins *ilh Sdbn 70rI)) of Divi.ion l
<br />of lh. B$iN 6id Pof6rio6 Codc. ird my lh.n.. it in tull h@ &td.frcd
<br />t0t11rto
<br />lr
<br />colllaucuoxJ.[ll}laclclilcr
<br />I heEby altrm uidr p.iahy ofr..jury lhd rhrc t a conslruclion LndinS r8.my for th. ,.rformane ot thc work lor eiich rhN p.mn 6
<br />htucd (sr.109'7. civ. c.)
<br />Attucalt.lll:claaArla!
<br />I hd*y afiim uidr tmdlry of pdjury on. of rh. followin8 dftI..!!'onr
<br />D.m.lilion P..mils Asltslos Notilicarhtr [.d.BlRcsulltions (1nk 40, P.n6)
<br />_R.q!t d L.n..of Noriliorion
<br />-l
<br />c.nify
<br />'hrt
<br />th. ,.d6al r.8llarioN rctbrdiry asb.rbs r.mo\al .R mi arplicobl. to rnis pDj<t
<br />.V, ..rl't ,no, , **. ,*n ,n'. aDl,licsrion &d srar. rhar rh. rrnle infomlion i. corer Lpdroonllywilha cny.nd counly
<br />ohovB mnlio*d nmDdy for
<br />h6ri,! r$6r. ,rne of r
<br />::'Truiff*.
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Building Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarifier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Piping
<br />Roof Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOUSPA
<br />P{rap/Drain Line
<br />Main Drain/Pool Piping
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Gas Service
<br />Water Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />Rough Plumbing
<br />Final Gas Test
<br />Meter Release
<br />FINAL 12110({ ';l\gb
<br />Notes R emarks, Etc
<br />Miscellaneous
<br />l*
<br />It ,-*.* n6 (
<br />.rdinaN6 lnd Sl.te l-!sr Elaroanr$ ild'n!
<br />Pdn l.. h,nrontrl)
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