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PLUMBING.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWIIER BUILDER DELCARATION
<br />I h.Eby afrm und( p.n0lly of pdrury llE , m.rcnq,t fhm E Conln.los Lians lrw for th. lollowins r.aFn (Sfc,?031.5
<br />Businsss lnd Prcfcssion Code): A., Cny or Counry *hth Eqoircs ! Frmn ro 6nrM( 1116. impmvc dcmlish or ersn !nr'
<br />{erurc. Fior lo ilt hs!4.. d$ Equiei rII q,plianr lor .u.h lEmir ro fiL . si8r.d s|lrcmnr IlEr hc or 3lE h lie!*d puruot
<br />ro rhc ForisioN of tlE Coitdcroas Liccnsd Lip (Chaprcr 9. Com.minB wirh S.cli6n 70fl) of Division I oflh. Blsituss and
<br />PEa..sions Codc) or fi4t lE n 3hc h crc$pr rhefrcm snd fi. b{r! lor rhc .lke.d .tmplior. Any vk lalk n of Sdbn 7011.5 by a(y
<br />spplicul aor ! p.rmil slbiccls lhe lpplic.nt h a civil pcnolly of ml mrc thd five hundEi dollrs ($500).
<br />_1, as ower of rlE prbFlry. or nycmphyes with w.g6 a lhct $h shFnsario.. *i[ do d. edlr rld llf, n,Elm b @r
<br />i,rcd.d or oficrcd for slc (Se.?O14, Busimss dd Proacssiotrs Codc: Th. Crirturoi s Lk M Llw d@i not .pply lo & owmr of
<br />rhc po|rny who t uildr or iqfts tlE@tr &d who dc r8h slt himlf o. hc,elf or tltreuSn hL or nd o*n ctrploycd.
<br />Imviled lhar $ch imFovlm sesl inlM.Ld trorcrcd lor$lc.,lhowB. r huildinS trnrfrowmnl ie $!d rirhi.om Fa
<br />olonFletiorl rhe Oe..r Bnir6 will h.E E burd.. ol Imving ihd rE o.3h. did ml hild or inpmrc thc FDIEIy for ItE puqDs ot
<br />-1,
<br />os owtrr or rh. ,mp.ny. am clusivcly.onrrcring *irh lienrcd coniEc'oF ro consttucl l,* prci$ (Scc 7Or4. BusF6s
<br />and Eof6sion Codcr Tnc CoflrGrols Liccnsc L!$ dcs rcr atplyro orncr oI ptuFny who bnilds or improvcs lhcrcon.
<br />dnd who .omocc lor iuch E i.ls wnh. Co.t6do.tO lisn!.d psuo.r ro thc ContEcrols Lien* L,s).
<br />-l
<br />o eremll undcr Selion- B. & P.C. for lhis rc&ni
<br />Ihl.: O*e.
<br />!OArcBE:.CI!MPJNTdfX,IN
<br />DEIIdX6II!]N
<br />I hcrcby oflirm u nd.r p.nolly of IqJUry onc ol I hc fo llow in8 dc.laEr ions:
<br />I; \r Cirlc. {nr rhc Dcrnrtr rc ol rhc Rork lir \[ich rlr Nnnir N isue,l
<br />_l halc lnd sill hlintlin sork.d compcn.lrh, iNuranc.. $ rlquued by Sction 3700 of lhc L.bo! Codc. for fie psfolro.. ol
<br />rlE work fd qhich rhis pcmi is i!$cd. My smt6 mnpctriltior insuoc .ricr and policy numb.r m:,ts\
<br />\,0 ,1.t.\r1
<br />-l
<br />enit, thd in E lcrfomrc of thc wor* for *hththhF,mn is issucd.l sholl rcl employ&yftei iieymuBr
<br />s * ro b..om subiel ro drc m*El otrqEns!|ior h$ of Califomis, ond a8B lhal it I rholld h.roc lubjccr lo lnc
<br />turkdl mq*nerhn lEvisions ot Sc{rion l?00 of th. ldbr C!d.. I shlll f6nh*irh onlp,y sirt thD$ ,mvhions..
<br />WARNING: F ilurc r. scur. workcs comrcnsorion ovcmBc is unhwfiil. ond rhnll slhj(r an .fltl.rrr b dnninll Fndllts lnd
<br />.ivil fincs uI ro ore nundEn rhousnd dollss (Sl0{,000). in lddnk,n ro rlrc .o.r 6l.onpcn.lrioo. &m8.s 0s providcd lor fic
<br />Smrion 1076 of rhc t tnr Crrdc. irtcrcsr Md Btlomy s fes
<br />n, l.l?.
<br />^""n*,,
<br />DEIIABAIII}N
<br />I hcrhy afiinb undd pcnally ol p.rjury thd I am liccnsd lndcr pmvision oi ClBpl
<br />of rhc Blsin.s ud Pmtc$ions Cod.. ,id my lic.ns is in tull foE rnd cff.cr
<br />lcom'tun.nrg *irh SNrhn 70(x)) oiDivnion l
<br />%"1o
<br />APPt ICA NT DT'CLA RATIoN
<br />I trn*,y aflinn uMc! rcnul'y oft'.rjury orc ofrhc lollosin8 d(l&uion\l
<br />D.fr,liti(,n P.rhnrAshcnos Norificilion l;cdcrlr Rc8ul.riotrs lTnt t0. P!n6)
<br />Rqurcd htrcr oi lloriaKarion
<br />. l.cd'lvrhrrrhcrcdc,rlrdLr'un\r.c0rdrnqr\h\ru\rnrrrl . n{ dnllEant lo th6 nnjd.r
<br />-l
<br />lrn'iy rhir I rxrv. rutl rhr urdrJrion uftl ndc rhJlhc obv. iniomurion iscodr I agN ro cotrDly wilh lll City.nd Counly
<br />odiMmd and Sl8rc Laws Ehin8 ro buildin8 construcrhn. ui rcItrc*nrlriv.\ ofthi\ Ciry anrl Counry lo cnrs upon lhc
<br />abdvc mnrioftd peDcny ftr inrrErrr'n
<br />Appllc.nl o. Aa€tri SiaBiurc:
<br />p",-n* * re,rnrl ------Pd
<br />1.L,1@
<br />Water-Under Iloor
<br />Gas-Underfloor
<br />Buildino Sewer
<br />Area/Storm Drain
<br />I nterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Pipinq
<br />Gas Piping
<br />Rool Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />It/ain Drain/Pool Piping
<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 />Rough Plumbing *rkrt*5q7*6
<br />Final Gas Test
<br />Meter Release
<br />FINAL 1/q I rs bv 5,1 lul.,+la ,4,{l6fo)
<br />Notes, Remarks, Etc.
<br />*", J,L.l4 .-,-o-,
<br />COIIIIf,I]I:UONIINDIN(i.&GENT.:I
<br />t hcrb, !fird undfi ,.Eny ol p.dury $at lhs. is a consldclio. b inS a8cncy for lnc pqfomun.. ofrhc qork lorwhichlhh Frmn t
<br />hs*d (56. l@7. Ci!. C.,.
<br />L.ndci.|{flm
<br />-
<br />t ndn.l Addns:
<br />-
<br />+
<br />UNDER GROUND
<br />Waste & Vent
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