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PLUMBING.INSPECTOR RECOBD
<br />APPROVALS ID/SIG.COMMENTS OWNI'R BU!LDI]R DEI,CARATIoN
<br />I hcrehy rfitm undcr p.nalry of pcriury rhlr I dn crcn,rr rio'n rh. co trct,r l-i.cD* liw for ih. loll{,*i're Eas,n (Se 7(rll 5
<br />Bu\iicss !'xl Pnrc\\nD Cdlc) Atry Ciry or Counry which rqnncs a p.rmir ro conntud. alrcr. nIJ)ro\c. dcm.li\h or ftnrrrny
<br />srruclurc. tnirlo ils nsu.ncc, iho rcqutcs rhc ipnlkrnr ior such n nnn i{,lilc r siStrcl satmnl lhd hcot !h. is li.ctr\.d Purnri.r
<br />h rhc !rcri\n,ns of rhc Conrruc(r\ Li.cn*d Lrw (Chrfl& 9, Connnch-.in8 wirh Sgcrtnr 7fiX, of Division :l oflhc Dusincs\ rnd
<br />Pior.\snJnsCod.rurrh(hcor rh{ i\c$mfl rhcrcnoNotrd rhc h"r!i\ iitr rlN lllcrcd cr.n,triotr Atryviollr'otrofSdiot?0.ll5byrn,
<br />nl'!Ii..nl ior r !.rnrir uhjccls rnc opplicf,nrft,rci!ilncntrlrrornor rorcrhntrnvchundrcddollaF(S5fir)
<br />-1.
<br />s owftr of llE plrpcny. or my .npt,yes wnh w.gcs s rh.i. sh @npcBslion, will do rlE wk lnd E sburm is mt
<br />inc'ilcr! or oft€rd fo, eL (SG.7044. Busimss dd Pr.a.isions Codc Th. Conlr.dois Li€ns Lru de! .ol .pPly lo s owftr of
<br />lh€ pmFny who tdldr or in{,mt6llx6r aid who do.s such hlt hitutlror hcelf ot lhmush nis or nq oso cmplo}t s.
<br />polid.d rhlr srch imprckftnts e Nl hl.nhd or oficrcd ftr sL ll hovctr. tlE hildu8 or impmwmar is sold widin onc Jtd
<br />ofsnptr6n, dE Owmr Bli*La will nsr llt h!d.n of pmlin8 rh,r tr or {E dil d hrild d irpow 0E Fo|El, aotr dE lr{ns of
<br />-1.
<br />!s owtur of rte i'mpcrry, !n cxchrivclt .onr,.ling wirh li.cn*d .onlr0dors to snsltocr llE pm.id lse 7lxl, susmss
<br />adl Pro6$ar. codcr Tic Conreror! Licc.s Llw d€s nor opply rD & 6wn.r of polcny sho builds or imlovcr rhcNtr
<br />d who .onrErs for such porc{rs {irh a Conrscrorls) li$nsd ptrlsnt lo llE ConrElols Liccn* Las,.
<br />-l
<br />am crenDr u.dcr 56r
<br />l,xr. (\'n.r
<br />WORI(ORS' COMPENSATION
<br />DECIdAAIIO!
<br />I hcrb, sffirn lndcr F.dlry or pcriury onc ol ltu folLwing delu.rions:
<br />lhrvcrtrdwilln n rinrCcnific.rc ofC.nsctrrr' SclFltr{rc litrNorkc^ conDrn\lrtud, \ FJvidcd ntr htScction:171X)olrhc
<br />I 160r Cul.. lor rhc p.rbrm3ncc o f rhc tork (tr e hirh rhc l{ nir rr i*u.rl
<br />_l hovcand willminrsin worLcs' conp..sdrion insursnc., as rcqliEd by Serion l?OO oflhc LlborCo.lc.lot th. pdfornMcc of
<br />rhe *ort lbr *hi.h this !€rmir is n{.d. My wdl{trC coniF.sarion in{rmc cMicr 3d p"licy nudbcr el
<br />I ccnilt finl in rhc pcrlorrume ofthc worl for which thh perdil ir L\flcd.l shall.ot cnPloy ony pc6oo in a.y mMncr
<br />$ &\ro hccome slbrccr ro thc workc( .oEpcnstion low* ofcalifomia. a.d lsEc lhat ill should bccom rnbid lo llE
<br />$0*6 comtcnsorion rmrisionr ofSetbn l7{D of(h. Ijbor Codc,I shall, fonn*nh.nnply wnh rhoePmvkions.
<br />WALNlNc: F,Iur. ro $curc workes' ompcnsrion covco-qc n lnhsrul, and shdll suticl 0n cnDlolt. lo sinindl lEnalris and
<br />civil iin.s ut ro oft hundrcd lhousa.d dollon ($100,in lddition rd rhc.os orco Epcnstion, dadscs a3 providcd lor $c
<br />DECLAf,{IIA!
<br />I hcrchtlr'lhtrrundcrpcnahyollcrurrrhd Ia lie.{d unddr 8,vi\ion or Ch{pb 9 (.ommncins *irh Sc.rio. 70 ))o{Diski{,nl
<br />or rhr Bu\incsqard Pmllssid$ Codc. {nd nrylncnsc is in tullnrc. a rff.cr
<br />ca! BIJClllrNrENDMiiliE!.Er
<br />I herchy rrilrnr uM.r lxnalryolpcrjury rhrr rhcrc n r con{tocri,n fundins nPcNy ror llt punmunla otrhc sork aor which rhi! Fnnir n
<br />n\kd (S.. :1097,Ci! C ).
<br />AIILIllrtNtDEcLAIAIl9l!
<br />I LJrby dtinn utulcr p(n,lry ortoju,y onc of rhc followin8 dccl!r.tions:
<br />Dcflelirion l'crmirs Asb.{o\ N.rifi.arion Frcdcr.l RcBullrions(l irlc 40- Pln6)
<br />-Rrquircd
<br />Lcrrc! ol N.rifi .,ritrr
<br />I ccnilyrh{ rhc lcdcml ESul0lions rcEurding a\t{sros rcnDvd a.c no' drplic$lc to Ihn pmjcd
<br />-l
<br />.cnify thal I lst t ad this 0ppltalion ull sl,L thar thc .hoE inlomlion t @@L I !8c to omply *nh !U Cny 8nd Cotr.ry
<br />odio,nfts rd staic h*s Ehrina ro tuildins sulr'ri,r rp.cscnLtivcs oflhis Cilyand Cbr.ryro ctrrer uFn
<br />'h.on)vc nrnri,nRl pmpcrry lor iBnc.r
<br />A0plica orA8enlSiFnllu 't/ , t/ t,4
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under lloor
<br />Gas-Underfloor
<br />Building Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Pipino
<br />Rool Drain
<br />Tub/Shower Test
<br />Rouoh Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Ivlain Drain/Pool Pipino
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Gas Service
<br />Water Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Rough Plumbing ?21 ls /r44fi),Uer! SwlL- DLI s,^,,'T
<br />Final Gas Test t.t *a,lA - t*
<br />Meter Release
<br />FINAL .-uzq fe)
<br />Notes, Remarks, Etc.\:/
<br />DATE
<br />P.nll4n n \ennllrz
<br />Back Flow Device
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