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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS oWNl]R I}U!t,DEII OFJI,CARATION
<br />I h.rcby rlftrn und.r |rnilry ('f Nrjury ihxr I !n .xrnlllr liom rhc L-o rados l,iccn\c tiw for rhc fdk)win8 rc0lnr (Sc.70:ll 5
<br />Bu\trs 3nd Prolcssim C(rtc) Aiy Ciry.r Coxnry whi.h r.rluics 0 lctmir lo con(tucr. rhcr. inrrro\c. &nrlirh '{ EFn Jny
<br />(rucrurc. prhr k' irs i*ui.c. sl\. rcqun$ rhc nppli.r fo! such pcrnrir ro nt ! \isNd drr.mnr rhd h. or shc is li.cnccd Nrsuor
<br />k, rhc fovi\ions of rhc Conrrn.rors t,icctrscd li* (Ch{rcr L Comcn.ine sirh Sc.ri,r 70(xr ol Divnim I ofrhc Bnsinc$ nnd
<br />Fdt\sions Codc) .r rhrr lr or shc n.kcnu rhcrcfnnn Md rhctsis lor rhcillc[cncrc'ntridr An! violrriooolS.{rion70.]15 byan,
<br />,mli..trr rr,. p.irnil subj$lslhc lprlicnnr lo{.ivilp{ml'y.rno! ucrnm fivc hund.cd dollar (S5( )
<br />-1.
<br />&r owftr otrlE Fo|Eny. o. my.nployes *nh w!8.s as th.n sb onpeN.lion. wil.lo ll* *trt d llt.nv.te b mt
<br />i.r.nrLd or oficr.d for ste (Sd.?044. Busift$ 6d PDtc$ioB Cod.r TIE Conlnciols Lims Law dca rel ePly to e o*m of
<br />rh. ptopcnr eho hiLlr or inprDE r@Grnwhod.RtuhN hiGclf ot h@lf or inrcuEh his or hd o*!.nphyc(.
<br />providcd lhd such iqmrmnk c mi intcnata orotftr.d rd sL. ll hoD.€. dE t{ildiiS o. in{eEmnl i3 $!d vilhir oN Fa
<br />of@lpbib( ,r Owmr Builir will ltst lh. h(hn oftmvine thar h. or slE did ml hliB or irymE dE por6y for 0E FlrFrc of
<br />L r oNtrcr.trhc flrpcriy. incvlu\itclycodr rirg rvirh liccnscdrodticrtrsro.on\tnrd lhc pojccl (sm 7(lrl. Bu\i'rcs
<br />rnd hotbsJoclrlc:'l hc Con&&k,\ I-iccn{ l-rw dod n.( rtdy ro.n ownct olnrc|xn, who htrird\ or l,rfm(r rhcrcon.
<br />rnd who coitn.G r.r ru.h lrcjccls $ilh trCo rfl.lo(oli..rxst pu*Lrni hrhcCotrtrrcln s l-iccns l:r*)
<br />I in.rcnd uDdersenon .8 &PC fordicrcMn.
<br />II}Bf,E8S:TAMTB$ITAN
<br />DECI.AMtrO!
<br />I h.reby ,fiirm undr p.nrlry of psjury orc of rhc followine dc.lanrnJnsl
<br />Ihrk d sill ,tuinrro r (tn ifi.dc ol (ir{fl n, Scl,:1tr\u'c for (orkc^ c.n[.n\!tion.is,rDvid.dftnbrsccrtr'n]7()(lofrhc
<br />trtxnCodc.forrh.!. nnMDc.otrhcMrk fnshi.[rhcli.rn,ir is n\u.d
<br />-l
<br />h!rc and vill mi.rah workcr' .onn n{lion insrhrc.. 0s rclui(d by Sdlion .l7m of ilE t$or Codc. for lh. perfomEN of
<br />rh. *ort tor whict rhir lemn ii ilsEd. My w.rk6 @q,c6otion iBtuc 6hr 3,!d Plty nunbct m:
<br />/1lk P,,'tek f n;<trzqnca-
<br />R 1 /o a
<br />-l
<br />ccnilythul in rhc r..for@nc. ofth. eork aor which lhh l)c.Dit is issu.d. I 3h0U @r cmploy.ny pcmn in lny m.nNr
<br />$ asro b.mm slbjccl lo lhc *ortcB coq)cnsraon lo$ of Cnlilom,a, and !8Ec ln l if I should bc.6m sub.iccr lo rlE
<br />woftcr.on,..salionrmvisions.tSslionl?0OofrhcLiborCode.lshall.fonn*ithoddywirhrh,cpmvision,..
<br />WARNING: Faillurc ro scurc $ortcn' conFosrrion covc.agc is unhwful. and shall iubjccr m cnploysr ro cnminrl |lctuhb4 rnd
<br />on. huniL'd rholsnd dollas (SllD,0m). i6 ddilhn lo ttr.osr ofcomPcnsuri.n. darogcs as prolided for lhc
<br />hc l,tn Crxlc. inrocsr and atormy\ t cs.
<br />/rq l*e7-
<br />IIEIIdEAI](,)N
<br />I hcEbylmrm und.r FnrhyoflErjur! rhor I u lien$n undcr t)oli\ion orCbalrcr 9 (onmncins wnh Sc.rt,n 7000) ofDivision 3
<br />of rhc Busimss lnd Pofc$ionr Cod., ,ri my lt.nr h in full foe and cllL{r
<br />*<x1 o8
<br />ao/rq /tr ( SeevteSr 'l
<br />lf,r'dcr'' Ad.[(s
<br />-
<br />dItuc NfDEllAad.lM!
<br />I hrlhy!fiinnundcr l. hyol rojury oic ol rhc i(nbqnr! dcclnrali,ins:
<br />Dcflxnirion l'cflnirlA\tr{o! Nori,i.rri( Fcdcr.l RcgularidN (Tillc,l0- Prn6)
<br />-Rcqutcd
<br />kllcr of Norifi .rhn
<br />I ccn iry rh,r th. rcd.r rcaulolion{ rsedirs dtf,(.srcnhvrl dc nor,pdicabL k,lhn I,r.t:cr
<br />2<l ccf,ily rhd I hlvc ,crd rhr rrrplr rrtr,n drl {,rc I hr rhc .bovc itrromErion t com.r I r*B ro comPly r irh lrr (: y rnd c.unry
<br />-ftairumc. ,na Srrrc t,r. . L,rinr ro hu
<br />'U 'nx
<br />r. srrucuun. anti hctcby aurhtriz. Etn*nr,rivcs of rhh Cjty 3nd Counry tu .trtrt uFn rrE
<br />ahov. mnliomd ooFfly for i.spccion llurrsr.
<br />Ap!lienl or Ag.nr SigMIuE:
<br />V- .t)z,t t,att
<br />/q t7
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Buildinq Sewer tL G[zt t tt 16.fif ,
<br />Area/Storm Drain
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Pipino
<br />Roof Drain
<br />Tub/Shower Test
<br />Rough 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 />Rouqh Plumbinq
<br />Final Gas Test
<br />Meter Release A
<br />FINAL -7 I
<br />I YM,lL
<br />Notes, Remarks, Etc.
<br />CONiIBICTQNIENDIN(iJqINCI
<br />I hcruhyrtfirdundd l.ialry.l rcrjury thir lhsc ir0(r{rudion kndirarlcmy lor rhc pctlilrruncc olrhusork tur *hichrhn t.nn n
<br />issucd (Scc. .lor?. Ci! C ).
<br />txnJr. NJnrc
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