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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.o\INER NUILI}ER DTJT,CARA'I]('N
<br />liusircs frl lk lisio O\!.) Any Ciry or (irtrry *hi.h rcquncs r lanni n, .onNru.r, rltcr. irn0rovc. .lcmoli\h or rcprn trny
<br />l,! rhc r.visionr oI rhc Cotrlruclors l,ir.n\cd liw (Chrplcr 9. (bnntncirrs rirh sc.rion 7fiD ol Divirion 3 ol'rlt tsu\i'rrs\ rf(l
<br />Pr.l.\sionsCodrrorrhrrtuorsh.L\rxcrlrrhcrcrrhrdrhchl\ntnrhcrllctL\lcx.N nnr.Anyvnnrli{nr.fSc.ri,n70.r15hyrty
<br />rtfli. roi. fci,n sublc.rsrhc rlpli.dr ri n.irilpcoiIr.l Nr Dntrc rlrD li!d hurltuJlolh^ l55uD
<br />I. tr\ osncr or rhc lRrFdy. or ry .nrdoyes sth sitcs \ rh.r slc .on{r-n$rnnr. r ill d., rie x olt u lh.ntuh n nur
<br />i .ftlcrl or oftcrcd hr srlc (S{ ?O!l. Dusi.c$ nnd ftolcssions Codc:'l hc Conrn tn s l-iccns.ljw docs.orapply lo aD o$n .ol
<br />llrc pmDcny who huilds or inDr)vcs rhcrs .:urd who dos {cn Fo* hin$dll.r h.rsclror rhtough his or hcr ow. cnDloyct\.
<br />Il(*idcd rharsurh inlxohmnr aE fln inrclldcd.ronard r(, \rL ll k,wcvo. rhc hlil,lir3 or inDft)vcmnr is $ld wirhin otu tlrr
<br />oi conrtldion, rh. O*Nr ltuiucr trillhrvr rlr $lrdrn ofrn,ving rhsr h. or shc dki mr hurld or imJror. thc poFny tn rhf, puqx,v of
<br />l. N owncr or rh. F,p.rry, am .xclusivcly conrracring wnh lkcnsd connldoF
<br />'o
<br />oisrtucr rh. l'.ixr (S.c. 7044. Busmsr
<br />lnd h!6shn Codc: Ttu Conrra.tor'* Lic..* trw do.s ftr lpplr ro & owncr of pm!. y*ho builds or imDrows rhenon.
<br />and vho .ontE.!s for such pmjets wilh a Coirmcro(9 licnscd ,'u6@t to rh8 Conractols Laccos. Liw).
<br />I rm.rcnrtl utrdcr Sc.lir
<br />UOBtrEII]I:OMIINSAIION
<br />DECLAMIIA!
<br />I h.r.by affirm undcr Fnahy of pcrhry onc of lhc followinS dcclnrlions:
<br />-l
<br />h!{ drd will minr0in a Cenific c ol'Conscnt r. Sela lns!rc lor *orksi c.np.n\d t r,al ,tuvnhd tur by Scctbn :l7m o, rhc
<br />Lnhor codc. lor
<br />'hc FriornEna of
<br />'h.
<br />rork lor which rhc pcnril t hsucd.
<br />-lhdca.dsilld.inlairworl.ricom!.nsdionisuBmc.&.cq!ir.nbySdion3?00oflhctiborCodc.rorthcFrfom@ofthc *o* ror shth rhir pcmr ie isoed. My sorksC omlEnelion i.su.m. ceir ud F,lty tudbrt @:
<br />o ,,o
<br />-l
<br />c.nify lhll in rh. Frforn[m. otllE wort for which ttt Frmn is is*d, I shdtl nor .nploy any p.Kon ih rny .Mmt
<br />e as lo bccotu slbjccr to rlt wo*c6 dn{rBdion L*s ofcllitomia. r.d !e@ lhr' if I slEuld b&om so$j&l ro rh.
<br />workeN omr..sarion pmvhio.s orScfion]700or.he Lrho. Code I shll. fonhwilhcomrly wilh lho* ps!isio6..
<br />*Al.NlN(i: Fuilurc lo scN mrtcrs ompctrsstion coven8c is unloqtul. and sndl subjer d .nploy.r ro dif,inal I'.mllix and
<br />civil lincs up lo onc hun&ed tlsuend d(Uss ($100.000). in add nn ro rhc co( of ..q*Nrion. drru8.s as provAcd for lhc
<br />DECI,AIAIIQN
<br />I hcrcby afirn undcr rcnoltyofperjury lhlr I a'n lien$d undcr Imlisn,n.fChaplo 9lom'refti68 *ith Scclion 7000) olDivnion 3
<br />of rhc Burimss and Pbfcssians Codc. dd m, liccn* k in tull fore nd cfae!.
<br />qO!$&UI.IIO!.IENDNIi.A(iINCI
<br />I hcrby !flirn rndc, pcnllryof,*rjfiyrhd !hs. isa.onsrrudhn lcndinS aBcmy for lhc lcrf"rmarcc oarhc*o lor Phich Ihis Frmil ir
<br />issucd {Sa. 309?, Civ. C.)
<br />APPI,IIANfDESJAAION
<br />I hr'6y afm under pcnolty of pcrjury onc olrhc lblboin8 drcl,rarion\:
<br />D..n,lirio. Pcnnirs^sh.{osNolinc ion Fcdcrol Rceul ioos(rn,c $- Pd6)
<br />R.qutcd t (cr of Norif .olion
<br />-l
<br />ccniiyrhar r hc lcdcrul rcsrlar io trs rslrdinsa\bcsrosrcmo\aluc nor aprlkrhL ro rhis p(&.r
<br />-l
<br />ccnify rhd I hnvc rad rhh ap ic,r ion dr, salc rhln rhc ,$o$ inlormtion is con(l. I sgE ro comtly wirh lll Ciry and Coun!,
<br />oilnr Q\ Md Srm. l,'r\ rulnrinS nr in8 .otrtudion. ,i hcEby lurhornc rcrrcsntarncs of rhis Cir y and Coumy 16 .nl.r trF)n rlx
<br />ltn,vc mnrioncd pmncny for ins
<br />I 7/rlt c '4ly/l-/- ]k )
<br />Water-Under lloor r
<br />Gas-Underfloor
<br />Building Sewer llrtlte t 'X^bt4/V rl
<br />Area,/Storm Drain
<br />lnterceptor/ Clarif ier
<br />Waste & Vent 4/rrl@ r 'nlata- ,k'>--
<br />Water Piping
<br />Gas Piping
<br />Roof Drain
<br />Tub/Shower Test
<br />Rouqh Water Heater
<br />POOL/SPA
<br />P{rap/Drain Line
<br />Main Draini Pool Pipinq
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Water Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />Rouqh Plumbinq
<br />Final Gas Test
<br />Meter Release
<br />FINAL s lrs lt{ (,4ndk/+ft
<br />Notes, Remarks, Etc
<br />COMMENTS
<br />UNDER GROUND
<br />Waste & Vent
<br />TOP OUT
<br />Gas Service
<br />-)
<br />,)?
<br />l.ndcl. Addrc*
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<br />r"",o8-11- /f
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