|
PLUMBING-INSPECTOR BECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OTVNIjR BU!LDDT I'ELCARATION
<br />I hcrcby rfllrn !tutcr Ffulry ,,f tcrjury thd I {n cicrpr riom rh. Conrrucro^ Li.cn\c Ii* ntr rhc f{,lkNir8 r.as (sLc.70ll.5
<br />tlusinc\s lkl Pr.Lsrn CGic) Ant airy or Gunry *hi.h Rquncs r lf,i,nir ro .on{n.r, rlru. nnri(ivc. dcftrlish or Elnrn any
<br />nnctur. nrior lo ns issuorce, lho rcquncsrhD rfpli.inr rbr \r.h t'ciinn b ib a si8rrcd sr cnEtrl rhd h.or snc is liccn{d ph! l
<br />io rhc J)ft)ri\i'na ol rh. C.trra.ktr s Liccnsci L.w lchdprd 9, Com rn.nrg wirh Sr.rion 7Un ol t)ivision :l oi rhe Busincs( and
<br />Pmrassi(nr\ ('odc) or rlDr ncor shc iscx.nu l[c.crionrnd rhcbd\is ttr rhc !l]c8cd cxcmptis Any viohliorofScclionl0.ll.5 [yony
<br />upplic!nr for. F nrilruh]cclslhc rrpli.anr ro rcirilpcn,lr!oln.r morcrhrn livc hundrcddnllnn (35(xr).
<br />_L $ owF of rlE |roF ry. .r m, cn0loyr.s wnh wrgca N rlEn sk @mpcnsrior. wi[ .b llr wo* &'d rr stndc B mr
<br />inrddrt or ofisr.n aor slc (SN.7044, Busircss .nd Pmacssions Codc Tnc Conrraclols LienF L.w .loca mr aI,F,y to an owid of
<br />rh.pbFny wt builds o, inp,ows rlx@n..]d aho d6 ikh h* N@lf or hcrcltor drcugh ht o. hcr own.mpl6ye3.
<br />pbvi.,cd llul sh iq,reffils d mt inLnd.d motu lor sL.lf.lxME E tDildirym nl{,lwrln is sld *lhinm Fr
<br />nf 6'il,lclbr llrc Owr Au ftr *ill hlE dr t{ .iolpmvin8 td h. or rrE dn mt h{in or inprDE tE poFry aor llE pttpo*of
<br />-1.
<br />ai owmr of ltu ,mFny. !m cxclusiv.ly conlr@lin8 wnh lenrd contelou lo snslrud llE p$jel (Sc. 7044, Bu,ims
<br />ad Rnftsih Codc: Th. Cohkeroas Lk.n.e Llw dcs ror apply ro o oumr of pmlErry who builds or impo!.r rhc.eo.
<br />.nd rho onta.ls Lr su.h pDj(B wilh a C! ndoils) IieiFd pu^ldl ro rhc C$ntmloCr Li..nr Lrw)
<br />-l
<br />rm.xcml uMcr Sdiotr- B &PC forrhi\ici\otr
<br />L rr (nrnrr
<br />UOBf,Ef,f,:ljOMTEIIAII9I!
<br />DEqIdBAIIAN
<br />I kr.hy af,lrn und$ Frdry ol pcdury onc of rh. lollo{inp dcclod ioos:
<br />Ihn\.r qill'tuinrri rCdnilic((ofcoi\ctrrk,Sclfl'r\urul{r$orlcnconllisii,,n.nsF,viJrdfttrbtSc.nli:lrlloufrh.
<br />Irbor (irdc.ldr rhc pdnurn.c.rrhc *ork lnr*hi.h rhc pcnnir i\ i\suc
<br />_l hrvc ond will roinhin *ort N compcnsalion insuraB.. ar BtriB, by Sdio. l?0o or rh. l,hor Codc. for lhc l,crformmc of
<br />lh. work ftr whth
<br />'hk
<br />pcmit My aort 6' conpcndb, i.summc cMtr a pli., nunb.r G.:
<br />t-4-{u o zo
<br />-tenily
<br />rhal in lhc Frformtre ofthc work for vhth lhk Frmit is issucd. I shlll nol cmploy lny I'.son in any md.cr
<br />s {\ ro b.enE sub}*r to rhc eoliod onpcnqrbn hws of Califomia. and !8rc lhr| il I sh,uld bc.oft subi{ ro rlr
<br />wortc6' om{m$l ion prolisiotrs of S*tion 3700 of lhc L.bor Codc. I ndl fonh*irh oflrly wilh lhoc povhiotrc .
<br />WAtNlNc: F,ilur. ro surc workcs' ..np.nsrrion ..khgc i\ unliwtuL nl shrll suhjN nr! cmploler ro ainri.ol lcntrlti.s Nd
<br />civil ntrcs up lo otrc hundnd ihou$nd dollffi (Slm,mo), in ion Io lhc.osl ol.onDcnsnlion, dom8cs as providcd for thc
<br />Sccrion 1076 olrhc tih).
<br />DEIIASAIII}N
<br />I h.rby alttn ufldcr rcnlhyoircrjury rhlr I ah lie"Ed undcr pn'vision orCnap6 9(.onftncinp wnh SBrion 7fiD) ofDivi\ion l
<br />of lhc Busiftss ald Pmtt$ions Codc. ad ny li.cn* is in tull LNc rnd .tfcr
<br />0"r", 5
<br />C(INSTRT]CTI(}N I T-NDIN(] A(;DNCV
<br />I hcEby ar'lirmundcr p(nrhyoircrjury lhir rh.rc n a mn{nEIn,n k.din8 l8crcy ior rhc pcnn.oErcc oirlE $ork tr shi.hthir trmn ir
<br />issu.l (SLr 1097. Civ C.).
<br />AITUIANI.DDI;LIAAUON
<br />I hsdry dnm uidc, p..ah, ofp.,jury onu ofrh. rolkJsins dcc&rorionr:
<br />Dcn{lirii,tr Pcrmih Asbcstos Norificaln,n Fcdcrul Rcsuhlinr ( rilb 40. |,fi (,
<br />-Rcqricd
<br />Lcllcr ol Norifi carkri
<br />I cdily Ih,r rhc rcdc.al rc8uh! ions rcBardin! dsh.{os r.tu)v,l ur. .or umlElbh to lhis tmirl
<br />-l
<br />.cnify thar I h,rc rcad thk spplica sd sltrt rhar thc ak,vc nrlonMriotr is romcr I arE Io ohDly wnh .ll Cny md C.un'y
<br />odinan.cr rnd sratc tiwsNlding ro hfi.by.ulhorizc rcprcsctrhlivcs oIlhk Cny rnd County
<br />rtlrc nttrri{rncd pfl'lcnt lnr
<br />,\pplicrnl or Ag.nl Signol
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under lloor
<br />Gas-Underfloor
<br />Buildinq Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />G as Piping
<br />Roof Drain
<br />Tub/Shower Tesl -77t ,/ft 5.W4s",14t+fl{
<br />Flouqh Water Heater 7
<br />P-trap/Drain Line
<br />Main 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 6/hlr^3Y.N M4
<br />Final Gas Test
<br />Meter Release
<br />FINAL ;/4A/l< 'i.h. rr
<br />Notes, Remarks , Etc.
<br />,€ozaz7
<br />Lcndd.i Add.s:
<br />-
<br />Pemilemmc(pnnt) \a
<br />POOL/SPA
|