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PLUMBING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildino Sewer <br />Area/Storm Drain <br />I nterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Pipino <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rouoh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />lVlain Drain/Pool Pipinq <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 zltrl to @r) <br />Final Gas Test a I <br />Meter Release <br />flHAt,,ttFINALilel,flo',/-r)t/ <br />Notes Remarks Etc. <br />OIVNER BLTI,I)ER DEI,CARlT'TI0N <br />I hcrchy alfirnr undcr ptrully ol p(rjury thal I am cxcrnpt lioill thc Contrrckils' I-iccnrc l,aw lirr thc folk)wing rcilson (Scc-70.11.5 <br />llusincs( rnd f,rolc{sion (ixlc): Any C'ity or Coutily which rcquircs il pcrnrit lo conslnrcl. lllcr. iuprovc, dcmrlish or rpair rny <br />slnrclurc.priork)ils issuilocc.0lsorcquireslhcrpplicanllorsuchlcilnilk)lilcirsigncdslillcitnl lhrthcorshcisliccil\cd pursuanl <br />to thc provisions o[ lhc (i,nlrrck)r's I-iccnscd Law (Chrplcr 9. Corilricncing rvilh Sccli(rl TlX)() ol t)ivision J of lhc Busincss rnd <br />nlplicantli)rnpcrtrtitruhjccrsthc ilpplicunlmacivilpcnrllyofrxiltrxrrclhrnll\chun(lrc(idollir{'ii5(x{) <br />_1.asouncrofthcproFrt].()rn1ycmplovccsuithrvagcslsIhcirsolcconrpcnsation.sill(lothcur)rkrftl tlrcstnrcturcirnrl <br />thc pr)[trty uho buil(ls or irnpmtcs thcrmn. xnd who docs such urrk hinrsclfor hcrscll or thrrngh his or hcr own cnrpk)ycc\. <br />ol coDrplct ion. th! O*ilcr lluildcr s ill ha\r thc hurdcn of pr()r inl thrt lrc or shc did not huild or inrpr(lr'c thc pR)Frcny for thc purfx)* of <br />srlc). <br />rnrl $'h() conlrnel\ li,r \uch projcets $ith a Corrlrrclr)r(\) Iiccn\e(l pilrsuxnl k) lhc (i)illrircl(n s l.iccn\c l,il$ ). <br />I smexemt under Sslion-, B. & P.C. for this reason- <br />l)atel ()$ ncr: <br />\1()RKt,.RS', ( ()i\t PIaNS,\I ION <br />I)t,t( t,,\la,\I l()N <br />l hcrchy rlTirm undcr psirlty of I^-rjury onc of thc lirlkru ing rlcclarrtions: <br />_lhavcandwillrruintrirr('crtilicateofConscnlhScliln\urclorrvorkcrs'conrpcnsalt,n.us p()vidcdforhyScctk)n37(X)ollhc <br />lJhor Codc. lhr thc pcrli)rilrrilcc ofthc work lbr which thc fcrilrit is i\\ucd. <br />lhavcandu'illnmintilinworkcrs'cotrrpcnsationinsurancc.as rcquircdhyScclt)n.17(X)ollhcl-aborCodc.forthcpcrfornranccof <br />thc sl)rk li)r which this pcrrnit is issuc{. My sorkcrs' conlpcil\illi()n insurtrnce canicr an<l Jrrlicy nunrhcr arcr <br />Policv Numbcr: Exoircs: <br />-l <br />ccrtify thal in ftc pcrformncc of the work for which lhis pcrmil is issucd. I shall not cmploy any person in any mnnncr <br />so as lo becomc subjcct lo thc workers' smpensalion laws of Californi8. f,nd Bgrec lhql if I sholld hccomc subjcct to thc <br />\vork€ts'compenstrtionprcvislonsofScction3T00ofthctiborCodc.lshall.fonhwithconrplywiththoscprovisions.. <br />WARNING: Failure to rccure workcrs' comlEnsalion is lnlawful. ard I subjccl an cnrployer to oiminal ;rculties and <br />civil fincs up to orc hundred thousnd dollds ($l k)of compcnsation. damges as providcd for thc <br />':,"'i'rlff\ftr intcrc(t and <br />I r-I <br />I hcrchy allirrr undcr pcnxlly ol pcrjury thdt I anr undcr provisk)n ofChaptcr 9 (commcncing with Scclion 70U)) of Division 3 <br />ol llro llnsinc\\ nnrl l'rolissions (ixlc. anrl trrv liccn\e i\ ir lirll lirtcc ntr(l rllccl. <br />License "1 4 <br />I hcrcby affirm under lEnahy ofFrjury that lhm is a <br />issued (Sec. 3097. Civ. C.). <br />ion lcnding agency for thc pcrfornuncc ofthe work for which this frcrmit ir <br />knder's Name: <br />hndcr's Addrcss: <br />APPI,ICANT IIFCI.ARATION <br />I hcrchy allinn undcr ;xIrlly ol pcrjur! onc of thc lirlkru'ing dcclarat kxts: <br />I)cil()litiotr ['crilril\-Ashc\tos N(ililicrtiol Fedcral Rcculdi(,ns I l itlc {0. Pnn6) <br />_Rcquircd t-ctlcr of NolilicrlioD <br />_l ccrlify that thc fcdcrslrcgulalions rcgarding ashcshs rcnrvul arc nol upplicahlc lo this f()iccl. <br />,}k,reud this application and slate lhat lhc is corect. I agre lo comply with all City and County <br />I reprcscnlativcs ofthis City lnd County to cnts ulnn lhekws rclstinS lo <br />rtxrr'c <br />,\pplicilnl <br />Pemritee <br />rhnl I <br />lir <br />aull$rizc <br />iTV-*.rw <br />a I I <br />U <br />l)rle <br />:!1a