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PLUMBING.INSPECTOB RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNEK BUILT}ER DI'I,('ARATION
<br />I ltichy arjtflr !n,lc. Fn h) ,,r Frlury rhd I .fl crcmrr liom ihc n)nkr.rtrr LEn{c Las nn lnc f{rlo*trrA I
<br />llu\inc$ r Protd(lion Cd,c) Atry Ciry or Counrt sl,ich r.qutcs r ltmn ti uon(tu.!. nlr.r. inrlnxc. dcnnnnh 'tr ruFn rny
<br />nnrkc. n 'trt) ir\ Gsurncc. rlso rqonrsrhc trntltrntrr Lr such Frnir h lilc a siB.cd nircnEnr lhur tEor \ht is li.cn{d ,rununnl
<br />ro rhc pn,vlbn\ of (h( Cotrt0(u s l,i(!trsrd I]q (ChrPrcr t). (innnEncing riih S(rion ?(Xx) ol Divisnrn .] ot rlr Btr\in.(\ ind
<br />Pnrfc!\irns Corlc)or lhlr if,or\h. i{ cxcmf hcrclionr $d rhc hnri\ kn rhtallcgcd cxcmuidr Atyliinrri{r.ls..riot70ll 5 bv irv
<br />trptlican( ii,rr nrii iriul,iccrs rhc 0n!1ic!trrto acirilpcnrlrrornor hturh$fivchunnrcd ollm($5(x))
<br />L rs oNrcr ol rh. px,|rdy. or mt cmfloyccs s ilh *rr.\ k\ rtun vft .u rNn\r iur. { ill do lhc *1nk ml rrl {trrurc ilxn
<br />inr.frldloroflorcnfrrs0hrsL\.r0,ll.flu\inc\{rdltola\{idsCdr'lh.(i,rlcntr'\I-kcn\cl.w(l.c\trorsfPlvt]0now.cr.i
<br />rhcpmpc y \hohuild\ornnt)nrvcslh.mn.rdw|odocssrhu.'khitrrrcllo'hc^cllo ht)ughhi\orhcro(nc'nplt,vcct.
<br />nr)vdcd r hrt \uch in,rrokmnr\ aE mn inrcfltldl o! ol]'rcd itr srk ll hr*ctr. rhc hriBing or imPnr.n.trr is sld silhh onc Fxr
<br />oI cun\rLri,nr, rh. osncr Buildcr $il harc nf, turd$ of F,rirg rlhr hc or rhc did mt h,ill or i,qrolc lhc PNtEly lbr ltu lLqr'{ of
<br />l.r\o$krofihcpinpt y. rncxclurivcly.ontrcrin! sirh li.ctrs.d..ntx.kFt,condoc! rlr Pi{)jN (Scc 7lll]l Btr\i'r'\(
<br />r PnnillhnCodc'lhcC.ih.rofsl-iccnscl.isdo.\norifplyn,annsnc..lF),--rrywhohoikl\orimrrovc(rhctcon
<br />rid eho.otrro.htuslchprol.ck*irhaConkd.tdsrltctrs.itrrurdnirhcCinnNror'rLi.cn\chw)
<br />I am .rcmpl undcr Sdion-, B. & P C aor rhis rc$on
<br />$A8f,EX5:I]qUI!NSANQN
<br />DDIIA86IUN
<br />I h.rcby rlftrn u cr I'cialry of p.rju.y oft ol rh. followi,rB dslarorio s:
<br />-l
<br />hlvc {n witl uinrrin a ccnilcsr. of Cor*nl lo Self lns!rc lot wdkds ompcnsoli.n.ss pmvidcd fo.tvS(li6n l7m of lhc
<br />tihor C.dc. for rhc I'crfotue 6fuhc work lor ahich rhc !.mit h hsucd.
<br />ill h.r lid will hia.raii workeB .oop.malion inslEncc, ar tqun d by Sdiofl lrm ofrhc Lih.r Codc. for lt. pdLmftc ot
<br />rhc vort lb, vnth thi.! p.rnjt is k{,n. My *ortc6' .onltneriod insuBmc @ricr lrd polEy numbcr rc:
<br />t\L trg I'v?D
<br />WARNINC: [.ihc 16 $m $!dcu @nFnsllion covmsc h lnlawtul, lnd shall sutijcd an cn{,loy.r ro siminol lEtulris.nd
<br />lo o* hundnd lhouqnd dollsrs lSlO0,00O). in ldditi.n ro rh. cosl of.omFodion. dtm8.. as rrovided fot rhe
<br />SNrion 3076 oa rh. Libor codc, intcrc( and axotuy r fccs.
<br />o",.,\l'1,(LO
<br />DECIABAIII]N
<br />t hcrhy 0ffirnrndd rEnrllyofpcrjury rltar I dnr liccn{d undcr nnvi\t,n ot Chrfrd 9{.onnrcrcirg sirh S..ri,n 7fiD) olDivhion I
<br />ol rhc Busnr\srid Pn,fcssior$ Codc. lod ty liccn$ i\ ir tull forcc .rld .ilccr.
<br />\0go\fl
<br />,,'",ll1l 'LO a*r-a*{t1
<br />IQXiIBI]CITON.LENDIIA-ASEX!:I
<br />I hcrcb, dmro !.d( n ullyof!.iuryth lh.E h,oIntu j6n hnding.8cky lor lhc p6fooBN otlhc work for whth rhk Fmn h
<br />issuM (Scc.3097, Civ C.).
<br />AITUIANLDICLAf,IIIAN
<br />I H)y Jinn undcr p.nrllyof F.j!!y ooc of lhc tolk,vn'g dclelIi(n's
<br />Dcmolirion Pcrmirs Ash.jos Norifi(.ln,n Fcdcrul Rcslllrtrn\ (li'I..r0, Pan6)
<br />_R.q!ned b * dl Ndi,kation
<br />-l
<br />ccnif, rhrr ihr rcdcml rcBulario.s E8.rdin8 a\trsrN rcmrnlarc n.r arPlic krolhirlrojNr
<br />-l.cnif,
<br />thll I hnw rcad lht applicllionud rllrc rh.r rh. tbor. i.formtion n cotur I agr ro onpl, wilhallCilvand Con.lv
<br />odirrnccs od Srde Lrw\ tolJrir8 lo huildin8 .!td h€Eby lurhort rc,,t$nralits ofrht Cny tnd Counly lo cnld !po.lh.
<br />ahovc nf,fliorcd potcny tor i.\pc.rt,n ru
<br />Appli..nl or AFenI siEn.lure:
<br />I
<br />""*U*-..,onor, M
<br />Ll ,,,,,\1LlLc
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underlloor
<br />Building Sewer
<br />Area/Storm Drain
<br />I nterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Pipinq
<br />Gas Pipino
<br />Roof Drain
<br />Tub/Shower Test
<br />Rouqh Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Main Drain/Pool Pipino
<br />Fill Linei 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 Plumbinq
<br />Final Gas Test
<br />Meter Release
<br />FINAL lzt 4A -fr'w
<br />Notes, Remarks, Etc
<br />DKMO
<br />l.cnifylh.l inlhc pertortucc of $. wo* for whthlhis p€rmi i{ krrci,I sh.rl not cmPloyaoylcson in any nRnnct
<br />r s\ ro hsm.ubj..l to lhc workm'sn.pcneri'n liws olcilifornia. and asE rhar it! shotrld tE om suhjcl to lh.
<br />so*.6 smp.n$iio. pmvhbns of Scdion 3700 of llE b},r Cod., , shsll. ionhwnh comply w n tho* pDvistonr.
<br />/.
<br />Lcndcis Addrcs
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