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PLUMBING-INSPECTOR RECORD
<br />APPFOVALS DATE ID/SIG.COMMENTS OIVI{EX BUTLDER DELC]ARATION
<br />I hcrcb, a,Im un.Lr pcnolly ol Fdlry th.l I M .xcmpl fmm tlE C.nuelm LianE trr lor lhc folowinS s$. (S€.?ol l,5
<br />ausinc$ lnl Prof€s{ion Codc): Any Cny or Colnly which rcquircs ! F1mir ro.o.rtocr, .ltd. inpror.. d.nbli3h or rlrt 6ry
<br />slrudur.. prior lo ns h$an.c, also ,cquiEs lhc aDplicor ror rucn t*mir ro fik r .igncd {dcmnr rhd h. or stu h li.cnEd pursanr
<br />ro rhc lmvl\ions of rhc Co.rrerofr Licnsed L3{ (Chai'r.r 9, Commrciflg *ith Sccrion Tom of Division 3 ofrh. B.sincss and
<br />Prcfcssaon Codc) or thll lE or .h. ir .rcrw thcErrcn ard rhc t6ir for thc alhgcd crcntprion. Any vi.lrrion ofseti,n 70,i L5 b, {ny
<br />llplkanl for ! p6'En subjats ln lpt,licut lorcivilpcmllyofnol mElhn fivc hundEn do0lrs (S500).
<br />-1.6.wn
<br />of rhe pruFrlr. or my cf,elorEs wiih waec. I rhcn eb omocn$lion, willd. dE rcrt a,ld tE stnriB is ml
<br />inr.D&d doficEd for sk (Sr.?044. Blsitus md PrDfssioNCodc fi. Co mlor's Lt.nF Lr* do.s ml.0ply lo d owftr of
<br />llE pmpdiy wlE brilis or inpioB tlE@tr ,!d who docs *ch wl* hidrclf or hd*lf o, rhougt hi. or ls own cnployccs.
<br />poridcd thol such inl9owrnls e ml inl.dsl tror.Ed for sL.lf, h.*.wi tlx hdd-og or in{rowenr is $ld wnhin om yrd
<br />ofotrplclbc tlEOwM aui!.rwi tus dr bud.n or pmvin8 thd h. or 3h. di! mr boild or inproh dE pbFry ror tlE lr{qbEor
<br />-1.
<br />as owncr of I hc ,,mp.n!, anrcxclusivclr.o.r.din8 wirh lic.nrd cont0cloB ro.onstrud rh. pmlcl (Ss. ror4. B6inss
<br />ad Pnr6sbn Codc:'llc Conlrlof i Liccnsc Lrw drcs nol rtrly to !tr oqncr oap,op.ny wio brilds o, imprcvcs ttcrcon,
<br />and who .onh.c lor such pmFcls wnh aCoorRddnr liccn*d pu^@r l. lh. Co .a.t6as Li.ctr€ 1,*)
<br />*l mcxcmpr undm Serion ,B & P.C. frrhisrcaron.
<br />WORXERS'COMPENSATION
<br />DECI.Af,AIIQIT
<br />I hcrchy amrmundcr pc lty ofIs,try om of rn fouowing delmrionsl
<br />Ihr\rr trnlnui' rinJCcnilicrrrolc{hcnit,S.laln\u'.6rtror[.^.onDrn\ n)n.r\ prtrnbd turbtSccr(,n:]7LUr, (hc
<br />Lahorc{xl.. ktrrhrI)lrlbrnuno oir[c $ork f{tr \hi.hrhc !rn.[ n i$u!(l
<br />_l hlw 8rd qiu minl&in sork6 comFnsllio. insumft.. .r rcquircd by SRlion 3rm of dE L.bor Codc, aor lht p.rf()mkc of
<br />t)crmil is hflcd. My wo cr' sq'.trslhn insuEmc cnicr $d poli.y numlEr 6c
<br />o
<br />-l.cnify
<br />rh in thc pelforme ol fi. *ork for ohtt rhis lcrmir is is$cd. I shall er crnloy a.y pcmn in my @G,e ar lo bc@m .ubtcl ro lne *ortcts'@Dl!.trrorion hps ofcrlifomia. a.d l8mc tll3l ii I should b..o!r subjel lo th.
<br />wod(6.ory)..iarionnnvi.ionsofSccrioolTmofrhcLltniCodc.lrh!U.fonhwirh@mplysirhrh.*povishns..
<br />WARNIN(|: Failur. ro s^.trE sor\cr' conrp.nsll ion corcragc ir unhqitl. lnd \hall tubJlrr rn.mplqtr h mmnrll*tulric!,nd
<br />.ivil finc\ op h onc hundhd rhousrnd doll r\ l$|(n,fi)or. in Jddirioo ro rh. co{ ol conD€n\.1
<br />S..ri({:1016 orrlr Lnhr C(xlc. il crc{ nid rnonu s ttc\
<br />'uuttl1 ?s1L
<br />,r4.,"r"o,,,,
<br />I ncdby !flnn undcr p.nalty of pcrjury lhd I an lions.d udLr lrevnion ofcnrd6 9 (@nmmirg *nh SelbD 7000) ot Division l
<br />of llE aBircs. 4d Prcf.$i.ns Codc. ord Dy lhmc i! in tull foc rrn .ll.d.
<br />^6s^t.ok4 2.
<br />'tuN 1IZuru
<br />IANSIAICIIONIEIDIIi(iTiENCI
<br />I hcrchyalrnuu.rlcr prnrltyol'pcrjryrhrl rhcrc isrcotrsrucrhn Lrtrdin8o8crcyInr lhc nr.lomumc orih$ork rffnhi.hrhA pcnn i\
<br />is{r.d (Scc 1097. Civ C.)
<br />AfPLlgANfDECI BAIION
<br />I lElby anim undcr pcnalry oipcrpry one ofuhc lollowing dNloralions:
<br />Dcnmlition Pcrnrils'Astrnos Notilica'ion icdenl Rc8ulutions (Inlt 40. Prn6)
<br />-Rcquncd
<br />Lctrc! ol Nol ili..riotr
<br />-l
<br />ccnilr rh8r rhc lcdcmlrcBularions Egudins adEsro\ rcmval!rc nor a lic krortisnmjc.l
<br />A en,ry ihar I h.rc cld
<br />'hb
<br />qplicdion nnd !r c rh,l rh. ah.k inforruion t comd. I
<br />ordinamcs .nd Stet tiws El,ri.B ro buildin8 oniE.riol| and hcr.by Mhoriz Eprcs.nla!
<br />,grE ro mn{,ly wirh lllCny trnd Counry
<br />rhrc nEnrn)..J ln)Irny for i'xtccrion
<br />,\ppli!Mt trr,\[.nl SiBnnitrrc t,rr! " r -
<br />UNDER GROUND
<br />Waste & Vent
<br />Waler-Under f loor
<br />Gas-Underfloor
<br />Building Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarilier
<br />TOP OUT
<br />Waste & Vent
<br />Water Pipinq
<br />Gas Piping
<br />Roof Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />tr4ain Drain/Pool Pipinq
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Water Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />Rough Plumbing t /t,1nv 5 \r,t
<br />Final Gas Test
<br />Meter Release
<br />FINAL 1/u /rb Js tot
<br />Notes Remarks, Etc.
<br />Gas Service
<br />y'q{arv>.
<br />Irtdcr. Addrcs:
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<br />/.'-r
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