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PLUMBING.INSPECTOH RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWN!]R BUtI,I'DI DI]I-CARA'TION
<br />I hcrchy alltn lNlcr penrlly of ner.loiy rhrr I d crcn{'r rtum rhr a rmntrr Liccn\c L{w titr lhc folk'wil! rtr$n (Sc.70ll 5
<br />B!\inc\\ ! l Proa.\\L,n codc)r Any Cily or C.unry *hi.h r.qurc! ( I'c.nrir ni con{ru.r. xlr.r. nnli.v.. d.mlish nr rclrn 0ny
<br />(ru.'ue. prior ri irr ilsu!trcc.0l\o rcqunc\rhr E,pliclnl ri)r $ch psn rr) Iilc a \ieNd (atc'mnt rhol hcor shc is licc0sd ,lursumr
<br />h rhc ,tuli\io r of rh. C.nracktr\ Li.cnscd Lrw (Ch0!rcr q. (hnnrenci.g *irh Secrion 7mO nf Divisi,,n I ol rlrc Busirr.s\ itrd
<br />Prrlsion\ C({lc r o. rhd hc or \hc is c&mtr rhcrfrum d rhc hr\i( nrrh.llLBcJcxcmplion. AnyliohlionolSc.rhn?0:ll.5hyony
<br />aprli.rnr lnrapcinir iubrc.c rhc .mli.anr h a.ivilFCMXyolmr nuc rhJn llrc ho drcd dolhil (S5([)
<br />-1.
<br />sr orM of lhc P,oFnr, or my cnployei snh wlgcs I rhct sle comlcns ion. vill do llt wk,!d dE nnEr@ ie mt
<br />itrrcid.d o.ofercd for $]. (Se.?()44. Ausines ed Prof.ssionrCodc Th. C.nlndor's Licne t wd@srclq,plyloano9Bof
<br />lh. toFry who bsilds or impmEs rl*6n, dd *lb drs Mh s* hidrlf o, h.ell q rh&!8h nt d ls o*n ctrploycd.
<br />Fotided rhar.!ch inllmEft s@erhtcn<knorol@toreb.Ithoy.6.t ttrildi.8 or inproEdnl ii $ld wrhinoft ter
<br />ofotrpbrio.. tlr O*ftr Buitte sill luv. rlE hrbr ofF.ti.s del lE 6r srE dit mr hirc .r i!!mw tlE FDpcry for ltl lulpor of
<br />!. 8 owre, or rh. ,,DFrry, am cx.lusivcly conrrad i"8 wirh liccnsd contr&loB ro .onnrud 0r frcrc.l lscc. ?044. Busincs\
<br />!d E fssion Cod.: Thc Conreror\ Licc.* Law drcs.or lnplylo an ownct orDoD.rly who huilds or imptovci theron,
<br />lnd who onrelr lor su.h ImjFls wilh a Conrncto(s) lk..scd pusMt to rnc C.nhcroli Li*r* L!e).
<br />_l mexcm,ll wds S.dton-, a. & P.C for rhh rcMn
<br />!!8f,Ef,5.:gTMIB$ATIO!
<br />D&CIdIAION
<br />I hcr.by,ltnm xndcr Fn,lryorFrjury.rc oflhc lollowin8 delantions
<br />Ihrrcifrlwillnun oir accnilic.lcol Conscnr n'Scll:tNUrc lor {orkc o'npctrsnriotr. as pmvidcd tot byS(rn,n:17(x)orrhc
<br />ljtxi cc{c.lar rh. Fnnnn.rcc of'hc uort hrwhi.hrhc pcr.rir i\ i\n'.d
<br />-l hlvc lnd will d.inlain wortcB com0cns{rion iNuENc. s ,.quied by Scl bn l7m of thc L,hot Co<h, for Of pc,fo.|l1.@ of
<br />rh. *ort for *nich lhis pcmn is is .n, My eo*6 @nFn.orion imu@c .ei(r .d policy nombcr G:
<br />PolicyNsnbcr: E pn 3
<br />-l
<br />ccrlify lh.l in thc pcrlormrc€ of rhc *ork l'or shkh rhir l'crmir h isstr d.I shrllnol cmdoy anypetun in anr D M
<br />$ !s xr hcc6r* *ubjccr ro rhc w.rlch'onD.nsalion laws of C0lifornh. lnl !8@ lnal ir I should b.tor subitr ro ilr
<br />so*cis Nnrpcnerion Isvirions orserion 37{n.rrh. Llt rCodc,I shall. tonhqilh onq)l, *irh rhos tmv&iotrs
<br />WARNINC: ljailurc ro slrc wor*cF ompcnsdion.ovcB8c is xnhw{ul, ond rhrll shj.{l an mnlortr ro 6imin.r p.Mlras.nd
<br />civil iscs u! to onc hndrcd rholsand d.lla6 (t100.000). in addnion ro lhc cosl ofcomlcnsario.. dlmgca,s pmvidcd fo.llE
<br />S..rn :l(,76of rhc Irtnrftxl..inrcrc{dndanormv ifc.l
<br />I hd$ynlllrn und.i !.nrlryofFrjury tlur I am liccnkrl undc! provi\ion nlchaprcr 9 (.onnNmirB *ilh Sc.tion'7(xlr) oll)ivisn,n.l
<br />.f rtc D!\ims md Pdrd$nrns codr. dld ,ny liccnsc n ir tull iorcc fld ctcrr
<br />Lj. @cb.r, Li6n
<br />c..r*!..K-
<br />C('NSTRI]C]I(IN I ITNDIN(; A(;FNCy
<br />I hcehtrflrmtrndcr lfn.lr,ol ticlur!Ihd rhcrc l\rcon(rucrion tndinga!.ncy tur rhc NrlirtBn.colr,r $ort ,n' shth rhn lr.ir ir
<br />i\sucil rscc l(14? Civ C I
<br />a.EtugNrD&ll 8,uI0N
<br />I hmh,nfinnundcr Fnulry ofncrjury onc orlh. rolL,wi.g dNlr iotrs:
<br />Dcnnnniotr Pcnils^sbc$os Noril'j$lio. fcd.nl R+uhlion\ fritlc 40. Pd6)
<br />-Rcquncd
<br />tlltcr of Nolifrlri('i
<br />-l
<br />cdrify thar l,E f.dcBl nsuL ions rcB!,ni.g .st slos rcnmvtrl e n.n ap,tli.lhlc ro lhii pruj.d
<br />_l Nnily rlllr I tuvc nad fiis +plhark'n ard sr.l. ltur rhc linv€ inaomr ion as core! I lem lo oq y wilh sU City and Counry
<br />odi@tr.. and Shlc Lrs! Nl,rine ro tuildinS conslMtioi. ui hcEby lurhodr rcprsniariv.s of rnis Cny md Colnly lo cnld uFn dt
<br />nbotc mnriorcd p!,!cn, tor iNF.ri.n
<br />L b:\lL
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Building Sewer
<br />ArealStorm Drain
<br />I nterceptor/ Clarif ier
<br />Waste & Vent
<br />Water Pipino
<br />Gas Piping
<br />Bool Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOL/SPA
<br />P{rap/Drain Line
<br />Main Drain/Pool Pipino
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Gas Service
<br />Lawn Sprrnkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />/A
<br />Rouqh Plumbing 6-lz-tY X.llt[l
<br />Final Gas Test L-7
<br />Meter Release
<br />FINAL /d/s//(hztrrrlel /0L.-
<br />Notes, Remarks, Etc.
<br />TOP OUT
<br />Water Service
<br />Applic.nl or Atenl Sltn.lun:
<br />P.mlre eme (pnrr):_
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