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PLUMB!NG.INSPECTOR RECORD <br />APPROVALS DATE ID/S!G.COMMENTS <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildi Sewer <br />Area/Storm Drain <br />ClarifierI <br />TOP OUT <br />Waste & Vent <br />Water Pi <br />Gas <br />Roof Drain <br />Tub/Shower Test <br />Rou h Water Heater <br />POOL/SPA <br />rain LineP <br />Main Drain/Pool Pi <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn er <br />San <br />Back Flow Device <br />h Plumbin <br />Final Gas Test <br />Meter Release <br />F!NAL <br />Notes Remarks Etc <br />afplicintli)rnpcrnrilsnhicct\thc rl)plicilrltorcivilpcnrltyolrx)ttrk,rclhxnlivchun(ho(l(killnrs(S5(I)). <br />srlc ). <br />irrtl $h() (()nlrrcls lin'su(ll D!(,iccls \!ilh x (-orilrn(lor(\) Ii(cr\.(l plrr\uili1 k) lhc (irnlril!lois I-ircnsc l,iw). <br />-lunrcxculntUldcrscclhn-.B'&P'C.t,orlhisrcason'I)rle:--()wner: <br />WORKER-I' C0NIPI.'NSATION <br />DI'CLAIIATION <br />I hcrcby aflirnl undcr penohy of perjury onc of thc following delsrations: <br />l,xlxil' ('(x,c. lirr lhc pcrl()rnrrncc ()l lhc work lirr which lhc pcrntil is issucd <br />lhc s()rk l'r)r u'hi.h thir pcrnrit ir is\lrc(l I\ly r\()rkcr\' (()rnl)cr\xti()il iilstrrrncc (xnicr ril(l lr,lict_ rrunrhcr arc: <br />Policv Numbcr: Exnires: <br />_l cenify thel in thc Jrcrfornuncc of lhe work for which lhis lrcrmil is issued. I shall nol employ any pcrson in any manner <br />s as to tx{orc rubjsl to the workss'compcnsation laws ofCalifornia. and agm lhat ifl stmuld bcrom subjcr'l to the <br />workers' comJrcnulion provisions of Scclion 3700 of thc Latnr Codc. I shall. fonhwilh comply *ith llns pmvisions.. <br />WARNING: Failurc to wurc workcrs'comlEnsalion covcmgc is unlawful. and shall subltct an cml,loyer lo ciminal FEnalties and <br />civil fines up to lhouund dollars (Sl00.0OO).thc cosl of provided for lhe <br />Sslion 3076 l-rhn intcrcst [nd allorrcy's fccs. <br />allirnr trcnalty ofpcrjury lhal I pmvision of Chaptcr 9 (comrrcrcing wilh Scctkrn 7000) of Division 3 <br />of lhc Busirrcss and Proltssions Codc. uxl lill lorcc aftl ctlccl. <br />Liccnse <br />I)rte: <br />I hercby affirm under ;rcnally of JErjury thal <br />issued (Ss, 3097. Civ. C.). <br />lcnding agency fo, the JErfomncc of thc work for which this Frmit is <br />Lrndcr's Namc: <br />[rndcr's Addrcss: <br />APPI.ICANT DECLARATI(TN <br />I hscby amml undcr Fnally of Frjury one of thc following dcclorolions; <br />Demlition Permils-Asbcshs Nolificstion Fcdcral Rcgulations (Titlc 40. Part6) <br />-Rcquired <br />lxtlcr of NolilEalion <br />-l <br />rcrlil-r lhrl lhc l'c(lcrxlrcgulnliorr\ rcgrtrliog il\lt\lo\ rcrr()vnlilrc rxil npplicilhlc l() lhi\ pr(Uccl. <br />_l ccdily thrt I hnvc rcad this applicxtion nnd \trtc thrt lhc fllx)vc inlirtrndtion i\k) comply with illl Cily und Counly <br />ordinarccs and St8le kws rchling to <br />ahovc nrcnltnrcd propcrty for <br />Appli(snt or Agcnl <br />Pennitee ngnre . ret) <br />ofthis Ciryand lo thc <br />J)eJalz w) <br />g- <br />l/t.