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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OIINER BUILDER DTLCAR TION
<br />I hcrchy .lilnn undcr ncnrlry ol pcriury rhar I un cxcnnr lom rhc Contrcttra Li(ctr* Ijw ln rhc ioll.wing rcr$r (Ss.70ll 5
<br />t,u\incss lod Prcfc*ion Codc): A.t Cty .r counly *hi.h rcquncs r Fnnn lo con\lrucr. ulrcr. inrpu,vc, dcnFli(h o, rcPln uy
<br />!d.rxrc, tii, k, irr i\su0,rc. rl$ rquncs thc dt'!li. trr rar such pcnnir lo filcn \i8 rJ {rrcmnr rhrr hco! shc h lic.n{d l)Ur\urr
<br />h rhc nm*i,nn oa rtc Co rr.ttr s Li.cn\cd us (ChrUcr 9. Connrcncins *irh Sccrnrn 7m0 ol Dilisbn I ofrl. Buiinc\\ rtrd
<br />Pn,n\sionsCodc).rrhlrtr or \hc hexcn|n lhcrcrio ond rhc h0sis torrlr nllcgcdcrcnrrrion. Atryvid iotrolsc.rirT0.ll Shyrry
<br />opflicml lnra Nnnil subjcclrrhc lnplica t,acivilpcnllryolnol'B,.rhrnnvohrndrcddolhrs($500)
<br />-1.
<br />es ow*r of rlE !rcFny, o. ny enplo)r.s with w!8ci !s rh.t sh oslpcNlion. wil do llt edt ed ftc ninw is ml
<br />iirclded o. ollcrcd fo, sk (5(.?044. BBimss cd Elacsions Cod.: Thc Conr&ld 3 Litns Llw &ca ml +ply lo u owM of
<br />lfu pEpcny who tDilds or ir{mes tlte[ ed sho d@s sh e* him*lt o, h.r*lr or lhrcugh nir tr ncr o*n cflPlorNs.
<br />rovided ltrr $ch iq!rctreill @ mt intc,i.d m ofici.d ftr eL. lL ho*.q.lhc hiuins n i@rnrcmfl Esldwnninonc yst
<br />of @nptdon. d* Owr B!il&. vill h& !E b'!d.n ofpmvi.g lh{ h. o. dE dn d hild or inFow thc pbtary fo! tlt F[Ibs of
<br />SOASDAIIS'IIPJIIAIION
<br />DECI.AIAIIQ
<br />I h.rcby aflim lndcr Fndry of pcjury oft of rhc follo*in! d€lrnraoBl
<br />Ihr(cr lwillnDn uirr(trli,icnrcofc.nsorroS.li-lo\urcf(trworkc^ conei\di,nras ptuvidcd i(tr hyScdi('n]?00 orrhc
<br />lrh,Oxlc, li)rrhclcrianMtuc olrhc work ld whichrl[ lEirni k n\ucd
<br />I hn!. rnd will tuinr,in *ork rc comrcmlrion insurorcc. ar rciun d by SNrion l70o ofrhe tibor Cod., for lnc p.rfornucc o,
<br />MyworkeF onrprnsalion insunncc ddi.r,M Flicy ounrl,cr m:
<br />s'2118
<br />-l
<br />ccnify thrl in lhc l,crformne oflhc wo,t fo, shth rht F.nar is irsucd.l sh,ll nol employary Pcmt in 8ry mdnN,
<br />$ N ro b.em $hixr 16 rt *0r*6' co,{x.stion hws ofcalifomi!. and astc rt r if| ih.lld h.cooE 3ubid to lh.
<br />e*cB conrDcerio. p@visionsofselion 3?00orllr btor Codc.I slEll fonhwnho,qrlysilniho*pmvisions..
<br />WARNINC: Failurc to Kurc qrkcs' .oolcnsai.n covcftg. is unlowtul. and shnll slhjst an cnDlort, ro nmintrl |f,Mnics md
<br />.iqrl fincs un h oFc hund'cd rhouqnd dcllr^ rll(t),rl{D)in addirion ro thc cosr ofcodpeoiarioo. dumg.s as povidcd for rhc
<br />S(lDn 1076 of rhc tiDor C.rlc, i.'ccs ond drlmy
<br />-,.I]l \Ln,oo*,
<br />DECIAMIIAN
<br />I hcrcby Jlinn undcr pcnlltyol Frjury lhar I !n lftn{n undrr nmvi\t,n or Ch,Prcr 9(.onrmncin8 wirh Sslion 7fix)) orDivinon l
<br />ol rh.lh\inc$ rd Pr.L!\n,n! Cod.. lnd nry liccn* i( in tul1loraandclf(l.
<br />lo \('2\\o\
<br />-"1 Dc\^ s--U
<br />(:(INSTRTI(ITI(}N I ENDIN(; A(;ENCY
<br />I hcrhy arfirh rndc. p.nrlryorp.rjDry'h!' rhcrc n acoNltu.tion lcndi.S rscncy ntr ih.lDn,rm.cc olrhc qork lor shicn rhis Fr.rir i\
<br />issuld (sL\ 1091. Cn. C ).
<br />a.ttu! llD[clAxallo!
<br />I ttnby afllnr undci l)cnnlryofpcrjuryonc olthc followin8 dcchralio!\
<br />l)cnDlirion Pcrnirs A\brdos Norin.arbn Fcdcrrl Rcgulriions (1irlc40, Pfi6)
<br />Rcqrircd l.rrcr of Norifi ..rion
<br />I.difyrh,t rhc fcd€rdlrcSul ions rusarding ashcsl.s rcnnv&l ur norlnplic,blc hrhislmitt.
<br />-l
<br />anilyrhlr I hlvc rudrhh aPliclrion ini {!rcrhar ihc atnvc inf.nmrion t coEccl losrNloco'nplywnhallCily,ndCounly
<br />ofllinlRcsandSrarcl,wsrlarinBroblildinCconqodion.r.dhcEbyaurtorixrctEsnlsliv.soflhisCnylndCou.ryrocnrdupon.
<br />ubov. d.riorcd pmFny for
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-underfloor
<br />Buildino Sewer
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Pipinq
<br />Tub/Shower Test
<br />Rouoh Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Main 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 />Back Flow Device
<br />/..1
<br />Rouqh Plumbinq 7"t7-Jg ,.w41
<br />Final Gas Test
<br />Meter Release
<br />FINAL vlr-tfu4 tt vryu^4rd -a)
<br />a1Notes, Remarks, Etc.
<br />Area,/Storm Drain
<br />Roof Drain
<br />_1, as ownc' of rhc nmpcny. !m exclu\i!.ly .ont r iIB wirh li(nsd . nkNk,^ tu .on(Nd lhc prcrc.l (Sa 7(H4, Bdlincs
<br />aftl lhfssifi cod.: Th.Contrlcrois Li.ctr\c t,!u docs not lprlyk, atr osn.r oi prop.n, who buildsor imtrolcs rhctcon.
<br />flnd who ..nrBd\ ror ruch l)mj€B sirh r Conri.!o(9 hrrMd puisum ro rne Conr.lcrols l.ic.ns tnw).
<br />_l an cr.mfl rndcr S(r i(nr . B. & P C. for rhh rcnson.
<br />lhrt (ltrNr
<br />k,nl.a. Nr r
<br />-
<br />lxndcis Addrc.{
<br />Appll.ant or ,lpcrl Slg@lure:
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