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APPROVALS DATE ID/SIG.COMMENTS oWNER BUII,DER DEI,(J,{RATI(}N
<br />I nc(by lafirm under n€nalry ol pcrjury rhd I !m cxcmpl forn rhc (-onrmcros l-iccns liw t r'hc lollowins rcav'n (S(.?l,ll5
<br />Busincss n Pofcs.t,n C(xlc) Any Ciry or Colnr! shi.h r.qrir\ ! frnir t, ..n{tu.r. alro, impnrvc, d.nxnish or rpln ,ny
<br />dnclurc. Drior h i\ i$u!trcc, uko rcquncs tlE {'tlicd for su.h |tnni ro filc! si8ncd snknrnr rhar hcor shc is licc.\ed fur{u!n'
<br />l. rhc lrovnions ol rhc Conrncror's Liccnkd lrw (Chapfui 9, Conr.rrcing wirh S.crtun 7(XD of Division I ofrtl Busincs\ rnd
<br />Pnrlersion\Codc)orlh.rhcor\hchcxcmfllhercforandrhcbNi\rorrhctrllcgcdcxcnuriotr.AnyviohrbnolSdk.T0lll5hylnt
<br />applicur fur a Il.dil $bjcds rl.r applica roacivilF.0lryofnorrmrcrh rivc hundrcd dollors MOO)
<br />l I*1.\ rtrmrnrrhcrn.Fn).u.rnycnlrl\,yrc\tr hr.'F..lsrhcr-J.$tr'|c\rtr.n,$rlld,'rtrudloJthunnrtuNrl'{
<br />ilrclrf, nrrrlrrcdnrslctsa7044.Bu\inc$atrdPrnrcssions(.d.:lhcGnrrttr\t-ic.n{tlwdo.snor,!!lyr.dnowmrol
<br />rhc pmpcny sho t^rilds.r iqnovs lhc@n. Md sho dms sEh mrt himsclior hcrrlf.r rhmugh hil orhcr.*ncnplott.s,
<br />piovidcd rh ru.h infnrvcftNs m fr, inrcd.d ur off.ft1 fttr slc tl h,s.rr, rh. huildi.S or nilr.hmnr is sru *nhin oft )td
<br />orcotupLrion. rtr o*ncr Briklcr willtuE rrE l,urd.n oi pmving rh{ ht or shc did tror build or impmlc $c tmFny lor L !'urlDsof
<br />-1.
<br />0s owncr of
<br />'hc
<br />tmt ny. am.x.lusiwly coftetin8 wnh Lc..sd conkios ro snsrud rh. pmj.Er (S(. ?o4,1. Busncsi
<br />rr, ftDftision Codc: I hc Conr.elols Liccnsc Law docs not oppl! lo an orncr of pol)crry *ho builds or in .ovci lhc.@tr
<br />I
<br />qho.onrtucrrf{rskhpml..rswirhrc.mrcl.'(\)licen\cdlr!r\u! brnco,nracroirl.kcnscliw)
<br />rdd Serhn- B. & P.C. for thir e&,
<br />DICI,AMIIOX
<br />I bcrcbyafrirmtndcr Fnohyof !.riuryoncof lh. following d.cle.riotrs:
<br />-l
<br />havc old will minlrin tr CcnifHl. of Consnr lo S.lalnsuE to, wo,k6l @nIFosrion. a prcvilcd for by Selior 3?00 or llE
<br />t$or Code, lor rlE Frforue of d. sqk for which rhc o.mn is issled.
<br />_l hNe ond will msinhin wortcrs' compcnsatior insunft., s EquiEd by Selion 37m of dE Lrbor Codc. for llt l,crf(IroN ot
<br />rlE wolk ftr whth thn pcmil ir is$.d. My workcu ohp.nsalion insurm cfid ad policy nunbcr m:
<br />*ork lor shkh rhis pdnir ir is\ucd. I shlll nol cnploy .ny p.^o, in 8ny mnrcr
<br />mFnslion laws of Calitomi,. .nd .gN lhnl il I snoub ta.om subFl to llE
<br />ftr lTmorrhc Lrb.r CuJ., I shlll, lonhwrh co'nply wiLh lhoc prc!hions.
<br />subjd to rhc wlkar .o
<br />*ortcn' conlFn$liontovhionsof Sc.i
<br />WARNING: Failurc to surc *o*cn' comtEnsoljon covcm8c h unlowtul. and slull subrrr cmplorlr to sininal FMllir ald
<br />civil fines !r ro one hun.i,cd rhousnd dollus ($100.0fi), i. addnion to rn..osr of cotrqnsarioi. darEgcs $ Ircvidcd aor rhe
<br />Sc.ri,)n :1076.rrLclrhtrC()d.,i' crc{rndartrN
<br />I hcrhy {rrm undcr !,..rlty of Fiury lhal I m lieo$i udr povision 6f Chrpt6 9 (on@rcin8 sith sc.li,n ?q)0) of Diviion 3
<br />of rhc Busincss and PotcsihB Cod. !d my liccnE is in nifl foN s,rd clT6r.
<br />ss:-LicM Numts
<br />AIILICANLDECLAI{IION
<br />I h.n:t, afiim undcr !)cn0lty ol perjor, o.c ol rhc lblhwin8 declnmt io.sl
<br />D€nnilion Pcrmns-AstEstos Nolificdion l-i{crol RcBuhrions lTllc 4). Pan6)
<br />-Rcquncd
<br />L.ll$ of Norificdi,n
<br />,-l ccnilirh rhc Itdcalrcsrhrioos rcsrdir8aihcnosrctrr,vnl e nor rrpliclhlc h rhn prqccr
<br />fu1*,,,",nr ,n.^...,.,,r |nnl-,Jr{, ail { !'hr,rturhn.rnr,mlnonrconc.r rrgrck,(nnpr!wnhdrr(iry..dthn y
<br />t{,jilel!!. rrl srrrr tr\\ r.lr'Il3 r' hu l,l !run{rucrnn.rndhcrchtrurhttriucrcprcso.rnrivcs()r$isCnyrnilCoutrrybcr$u0rrlf
<br />ak'v. rtunrioncd lr.pcny for in
<br />Aprlionl or Aa$t Siget -d\Ser5
<br />UNDEB GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Building Sewer
<br />Area,/Storm Drain
<br />lnterceptori Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />L,as Piping
<br />Roof Drain
<br />Tub/Shower Test
<br />Rouqh Water Heater
<br />POOL/SPA
<br />P-trap/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 />Sanita ry Sewer/Cap
<br />Back Flow Device
<br />Rou gh Plumbing
<br />Final Gas Test
<br />Meter Release
<br />FINAL /-3/- 19,t Uel-l7g va)
<br />Notes Remarks Etc.
<br />I
<br />PLUMBING.INSPECTOR RECORD
<br />Po;cvNumhcr: FrDlrc\:
<br />goN[IagcuaN.LlNulNc-alirNlr
<br />I herchy nfimn crlcnrlryolpcrjurylndlhscisacotr(ruclionlcndinS{cncylilrrhclcrfonrmccol(hcsortlnr{hichihisJrrn,iri\
<br />issud (SL{ l0i)7, C'iv C ).
<br />trndca\ Nr rc
<br />L.ndcr. AddE*
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