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PLUMBING.INSPECTOR RECORD <br />APPHOVALS DATE ID/SIG.COMMENTS ()WNl:R BtJtl,DllR I)1.:r,('A RAI ION <br />applicrntl'rrrrptrurit\!hjcrt\thc rpplicxillloilci!ilfctriltyo[ilolilx)rcthxnlilohtril(lrc(l(lollilr\(S5(x)) <br />_1. il\ ()wncr ol thc pr)l{rly. or nly cnlpk:yccs with rvrgcs as tlrcir solc conrl)cisili(,n. lvill do lhc s(nk rkl lhc slrclurc i\ i(i <br />srl l <br />_1. as owncr ol thc Jtr()pcfly. rnl cxclusiycly conlrxcling s'ilh liccnccd coillrilclor\ k) construct lhc p()jccl (Scc. 704,1. Busirtcss <br />and Pnrti:sskrnCotlc:lhcConlrnctor'sLiccnscl-awdocsnotapplyk)anowncrol'propcrtytr'hohuiklsorimprovcslhcrcoo. <br />ilod who contrncts li)r such pft)jccls wilh n Corrlrrclor(s) liccnscd pursurill k) lhc Conlraclor's Licc[\c l-nw). <br />I urncxcilrDt undcr Scclioo-, B. & P.C. li)rlhis tcrs(nr. <br />l):rlr ()rrntr <br />]TI}BtrE8S:I;gMPTNSAIIQN <br />DECI.ABAIII}N <br />I hcrcby trffirm under pcnnlly ofFrjuryonc oflhc followinS deldalions: <br />_l hnlcdndlvill nHinlrirxCciillcatcofC(,n\cnlkrSclflnsurcfors(il'kcrs cotrrpcnsxlion.{s proli(lcdli)rhyScclion3T(X)ol lhc <br />[,xtx)r Codc. for thc pcrli)financc oflhc work li)r which lhe lrcrmit is issuc(l. <br />_lhavc0ndsillnuiilloiiworkcrs'cornpcnsrlioninsurancc.as rcquircdhyScclk,n.lT00ofthcl.uhor(ixlc.forthcpcrli)rnhnccof <br />lhc lvork li)r which this prrrit ir issuc{. N'ly sttrkcr\' coirJtnsdlion in\urilrcc crnicr nnd fnlicy numhcr rrci <br />Policy Numhcr Erpircs: <br />- <br />WARNING: Failurc to surc worke6' omFnsotion mveEgc is unlawful. 6nd shall subjcct an cmployer to siminal Fmltics rnd <br />civil fines up lo orc hundrcd thoustrd dollars ($100.000), in addition to the cosl of comlrnsation. damgcs as providcd for lhc <br />Satkrn 3076 of rhc Labor Codc, interest 8nd attomy's fes. <br />Applicantr <br />I ICENSED CON'IRAC'I'oR <br />DECLARA'I'I(IN <br />I hcrchy rlfirnl uldcr Irulty of pcrjury lhut I aN liccDscd undcr provision of Chcplcr 9 (conurrncing with Secti(D 7t100) ol Division J <br />of thc Busincss ud Prolcs(ions Codc. {nd nty liccnsc is in ttll lorcc artl cllt'ct. <br />Liense Class:-Liccnsc Number: <br />CoDtrnctor: <br />W <br />I hcrcby lffirm undcr lEn{lty ofpcrjury thal thm is a conslruction hnding sgcncy for the performncc oflhc work for which lhis lEmit is <br />issud (Ss. 1097. Civ. C.), <br />bndcr's Nare: <br />- <br />Lcndcr's Addrcss: <br />APPI,ICANT DI:CI,ARA1'I0N <br />I lrcrchl allirrn undcr pcnrll v ol pcr jury olc ol lhc li)lhr$ i0r (lcclnralions: <br />l)crn()lili()n I'c,ilrit\ Aslr\t(,\ Nolilicalion l:c(lrrill Rcrnhli{)il\ ( Iillc {l). I'irl(i) <br />Rcqrired l-dlcr ('l N(nilicflli(nr <br />_l ccrtily thal thc lcdcrrl rcgulillions rcgil(ling ashL\lo\ rcrnr:valarc nrrl rpl)licxhlc k) lhis lrojccl. <br />irh()vc rncntioncd l)rol)cIy li)r irl\pccli()n purlx)scs. <br />Applicinl or A8ent Siguture:l)atr: <br />I\'rilrilrr ilnilrr ( t)riill I <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />lnterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rouqh 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 />Sanitarv Sewer/Cao <br />Back Flow Device <br />Rouqh Plumbinq Uq).2c)tlcZT <br />Final Gas Test <br />Meter Release <br />F!NAL V-zt-ut il LrJ rttt/4 /-2 <br />Notes, Remarks, Etc. <br />l)Bte: