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PLUMBING.INSPECTOR RECORD
<br />APPROVALS DATE tD/stG.COMMENTS OWN!]R AUII,DOR DEt,CARAl'ION
<br />I hcrcby rlftn undcr nenall, ,)r Nrjury rhar I m cr.'npr rrom rht G r&ror{ Lic.nsc L,lw ior rte rolk)wiu r.asfl (Scc 70ll 5
<br />Burinc\s { Pr.fc\sion Codc): ny Ciry .r Cdnry qhi(h rcqut r . p.nnil lo ..nndcr. rlr.r, nnniov., dcnnlish or .cFir my
<br />sru(ruic, jtrnx b irs issur.c. al$ rcquircslhc rpnlicul f{tr uch pcrnrirk' fil.a signcd srdcntnr rh hcorshc i h.'atd ltrFUJnr _
<br />ro rh. pmvrids of r)f cotrtr.rois Licctrscd Lnw ichrnlcr 9. Com cncing $i!h s.criod 7un or Divkion .1 ot rlrc Bu\in.s rnJ I
<br />Protsn'nsCodc) orrhrrhcor\lE is cxcmrl rhcrclrom rnd rhc h is r{r rhc rllc8cdcxcnDrio. Aflyviol{nnrorSc.ri,mT0.ll5hyiny
<br />arplicunrtorrpcnnirsuhjccrsrh.rpplicrnrbrcivilp.trrlrydrnornxncrh in c hurrlred doll$ (S5(n)
<br />Lrsoqncr.,rhclrrlrrry.ornry.nrpkDlc\sirh$rgc\r\lhcns,lcorrLnYii.r.silld.lh.wo {nd rlE (rucrrc is nor
<br />irncndcJ or oficrcd lir \!lc (SN 7l)'1.{ Busi]rcs\ rnd t\otu\snrN Cod. Th. Conrra.loi( Liccn* L!$ docs nor lplly ki rnosncr ol
<br />rhc pn,pcn, { lr hilds .r i'npros rhcmn. r whodocssu.hsorkhi,n\.llorhcr{llorrhiouthhisorhdo$trerPl.yccs.
<br />pmvidcd rhrr such i'npn,vcntnrsrtoiori'.idcdorollutodnn{L.ltlrm.vcr.rh.huiuiiEori,rpnvcninri\*rUsihir'a'.)tJr
<br />oiconrpbrion. rlE O$ncr Buiklur silltulr rhc burdcn of prclnrg rhd hc or shc dd nor build.r iqrrevc 6c rnFny fttr rh. rurP{ol
<br />-1.
<br />as owmr of rhc pmpcny. !ncrclnsivclyconradinS enh li.e.scd conlEck s locon(rud lhe lrojcd {Se.7044. Busilc$
<br />snd P,trtusk n Codc: Th. Conlrocrols Liccnsc Law docs not aptlylo !. ownfolproPcny who builds or improvcs liereon,
<br />and who onlracc lor suh pmjccrs wirha Coiracro(, licc.scd lu4ud' b lhc Conlracloas Lien$ L{w)
<br />-l
<br />!n cxcmpr rndcr Sccfion- B. & ?,C. fn rnis r.ason
<br />Drt€:- OPmr:_
<br />IOIf,E8S:.COMTEIIAIION
<br />DICIdBAIII]N
<br />I ficrcby aflnmundcr pcBlry of F,jury ok ofrh.lolhwi.g dNlamrions:
<br />lhrvc Bi sill nni'nxi'1 i (tdill.rrc of CoNcnr to Sclf lNrc for $orkcrr compcn\rti.n. N Pn,vidcd ()rtySc.li{[]7($olrhc
<br />Irtxr(:iatc. f{r rhc pcrf{nmn .. ofrh.work tu whichrhc llcflni k n{rcd
<br />lhavcandwillm0inlrinworkerscompcnsalioninsurancc.asrequtcdbyScdion3T0ooflhctrborCodc,forrherdform..ol
<br />lnc work for wnkh thh pcrmil is Gscd. My *orkcE sipcnsalion insurdc. .dnicr tnd Plicy numbcr rc:
<br />-l
<br />ccdit, thlt in rhe l]erfo@rcc olrhc work aor which this pcrnl is nsucd,I shlll nol cdploy,ny tcMn in lny manncr
<br />sb as to b..o@ subid ro lnc wortsl smrcnsalion hws of Califo.niu. dnd ag@ rhar if I shonk bBom subject lo lh.
<br />w6ike,i @mpeosarion provisions ofSction 3?00 of rlrc L3&, Codc.l shlll. foahwirh@mplyvithrhos. povtions..
<br />WARNIN(;] Fsilurc lo *curc workcs' comlensafion @lcEac ir unlnwlxl. Md sh l suhirl an cmployer lo dioinal Fmhics otrd
<br />.ivil nncs u, ro onc hutrdrcd tholsand dollds ($l
<br />Q,;-;.*
<br />-:-s !c p.ovidcd for thc
<br />Ser ion 1074, nf rhc I ilnr cidc. intcied and diomv
<br />,-n2-z-o/8 ,*z
<br />DICLASAIPN
<br />I lfrby altlrn undc. lcnolty of pcrjury lhol I !m lie *d onAcr povtion of Chaprq 9 (comncins $ilh Seclidn 7l)00) of Divkn,n 3
<br />of rhc ausinc$.nd Pofcsrn,ns C.dc, &d my liccns. is ir full foN ard cftccl
<br />o-
<br />coNslnlcflaNl.lNDtNc-dclrcr
<br />I hcrcby ninn undcr Fnrlry olpcrjrrr rhrr rhc'. i\ r..onddi,n lcndirre rgqEy in lhc Prrlo'nBn.c urrh. work tur which rhn P.rnrir is
<br />i\\tcd (Src .1097, Civ. C )
<br />AIPII{;ANLDEIIABAIIAN
<br />I ln$y fiiro u.dcr pcnllty olFrjury onc orrhc r.llowing dc.l,rarnrx:
<br />Dc.blirion P.nnireAshcslos Norificlrion Fcdc.ll Rcsulario.r Onk 40. Pan6)
<br />-Rcqutcd
<br />L.!cr of Nolifi .ario.
<br />l.cniry rhri rhc fcdcr0l Egulllions Esudins a\bc\ro. rcR)vd rc nor,ptli.ablc ro Ihn pmjccr
<br />-l.cnify
<br />rhal I hivc rad rhn amlicdrion Md {arc Ih0i thc obv. nrfornrnlbn n corcc!. I ase ro.omply *nh o0 Cilrand Colnry
<br />o_d'rJn.c.JtrdsrrtcLJtr\'cLrinEr.bu'lii,:l!.rq{ru,r'o..{lrmh\xurnorucrcFc{nkr',r.i,lrhFCyand('ounr)rocnlc,uF,nrhr
<br />il;:-::.:,il:*-XQ= Q --'----- z u^", 9'7o'z"t b
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Buildino Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Pipinq
<br />Rool Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOL/SPA
<br />P{rap/Drain Line
<br />Main 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 />Rough Plumbinq
<br />Final Gas Test
<br />FINAL b-4"/g //*5/.@)
<br />Notes, Remarks, Etc.
<br />Gas-Underfloor
<br />Meter Release
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