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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE COMMENTS OWNER BUILDER DELCARATION
<br />I hcrcby amrm undcr p.nolry of Frhry rhll I m .x€mfl lmn rhc Conlo.rou Liensc t w for ltc follo*inB to$n lJ.c.?ol l ,5
<br />Busincss and Profession Codc)r A., Cir, or Counly which ,.quiBs o Fmil ro snrlro.l. ohs. inqrmvc. rkmllih or epqs ey
<br />shor.. lrbr ro ns Lssuamc. rho rclliEs lhc apt licmr for such Fmir ro fih a sisftd nlrcm rhd lD or shc b liccnsd puE;d I
<br />to the lovhions ot rlE Conrrldor\ Li*.ed trw (Chaflo 9. ComrcinS with S.clion ,0m of Dilkiotr I ot rlE Blsinc$ .nd
<br />Prcfesrio.. Code) or lhar lE o, slE is .r.6pl lturdrom md lhc bdsis for lh. dlcgcd .rcq)lion. An, violalion otscdhn 70.11.5 by any
<br />{plicanl for a p.mit srhjck tnc ryplicrnr to ! civil pcnalry of rcl nre rhM nvc hudrcd dollas (1J00).
<br />-I.
<br />* osn.r ofrh. lmpcny, or my €mplotr{s *ilt M8.s as fi.t solc sn$c.s.lion. wiu do dE ro.t &xt lrE ,rEtE k ax
<br />inrsdcd or o0crc<l for sh (S6.1X4, BuliE* od Profcsi6B Co<h: Thc Conlrftols LicM l-w docs ml E l,ly lo an osft, of
<br />lhc FDFdy who tail&or in+rsE tlE6n. o who dG sh wrt timrclt or h€Nlf or rhotgn hi3 or hcr own ei{,loyes,
<br />!rc,id.n filt such inl"orftnl! e nor inlcid.i oi otleEd for e!. lt tbwch, iE building or nrplwm.t is $ld ,hhi. oft ]td
<br />of.onplclion, tlE o\,mr Buih.r wil hlE tlE tddcn ofFovins rhtrr h. or $e dil ml build or iqnor lnc 0EIEry f.r thc purpos of
<br />-I.
<br />rsown..orrhc !m!.ny. rmcrclusielyonrradin8 with liccns.n coirEcro6roonnrucr rlr Fnjd' (Se. ?o44. Busincs
<br />dd ft.fGsbi Code: Thc Cd.r.a.roc. Li.cns. Law do.s rcr {ply ro r. owncr of poll.rty who brilds or imFov.s fi$con.
<br />and who onrsB aor slch pmjcdr wirh 0 ConrEcto(s) liccnscd pu^uam lo fic C.niractois Liccns. Lav).
<br />-l
<br />m.rcmpr lndcr 56l B. & P.C fo. rhli rc.son.
<br />l).h
<br />loxf,E8s:cQMPillarroN
<br />DECI.AAAIQN
<br />I hercb, amm lndr p.Mlry of Frjury ox of dE fouowin8 delmrioNi
<br />-l
<br />hovc sd will mimain . C.niaElrc otcoied lo Sclf-lN@ fo m{GB omFnsrioi. as ptuvidcd for by Seion 37m of lh.
<br />Libor c4dc. for llE pafo,rrM. of tlE qort ior Bhkh fic ncmn i! isucrt.
<br />I hlvc trnd will Minhin *orkcr' comncflssr ion insunrce, ss rcauied hy Serion l7($ of th. tjhor Codc, for ltc pcrfomme oa
<br />I is i\sucl. My *ortcr' compcnsalion nNu,ancc cdi.r arxl r.licy numt*r ec
<br />q 2?'<l. t-t
<br />-l
<br />ccnifylhar in rhc pcrlormncc ofrhc work 16r sni.h rhh Frmir is i*ucn. I rhtrll mr.mploylny F€mn in anrnuN,
<br />$ {s ro b.sm slb}Er ro rhc wo*da comF.salion lawx ofcalifornis. and sEEc lhll ifl thould b..o@ sbjcct to llE
<br />woi@s smFnslion povisions ofScction 3?00 oflhc Labor Codc.I $!ll, fonh{iih smpl, wiln ihos ,mvisions..
<br />WARNING: Frilud t. *uc work.is co.rr.ns0lion covcmgc is unlswfrrl. md sh3ll slbir( an cilpk,$r to aininrl Ftuhies and
<br />.ivil finc\ xp ir onc hundrcd rhous0.d dollm (SIU),UD), in .dd ion lo thc cosr of o.alion. da@gcs .s providcd for lhe
<br />rhc bbr Corr.. inrcrcslond orrormy s fces
<br />IJ&II.ABAIIII!
<br />I hcEby trmrnundcr pcnalty of pcrjury lhur t d liensd undcr tofii.n 6fCh4rd 9(.omnrncnrS wilh Ssliotr 7()()0) ofOivision I
<br />or rhc Busincssdnd Pnn.ssions Co{lc, nn my licensc ir h full forc ud clIsl.
<br />l0o7/A?,
<br />coNuaucuoNl.[NuMidc[Nll
<br />I herht !fith trndcr rrnDhyotp.rjury rhd rhcrc is a.onnructb.lcndinS o8cnc) for rhc I,.rfomn.. orrhc work for whth rhir IE n l ir
<br />nrucd ( sG. .1097. civ. c )
<br />A.TII.ICAITLDES.IIBAII9N
<br />I lfrhy xrirnr umlur pcnrlry ort).rjur) onc ollhc lolloqnrB dc.l,ntriotrs:
<br />l).nn,lirnrn lc!.irs A\t(no\ Noritud i ltd.rdl R.!x[rnn\ lTirlc {0. t'rn6)
<br />R.qtrn d l-ctr.rolNorlftr{iotr
<br />l.cnilirhd rhc lcdcnl rcrulatiotrs ES0rdlnS (sbc(os rc,nolilarc nol lpllicablc t, rhi\ tirtd.
<br />f..*r,nu , ** .*, ,n,r applicatn,n rtol narc rhar rhc rh,vc intairndn,n i\corccr ltrsreloco.lplr*irhlll(iryriilcounty
<br />ordinlme{! sr.rc Llws rchring ro buildii8 ..ndo.rion, aJrl ivcs of$h Cny und Cou.(y ro cnb xro. irr
<br />ahovc mnriomd pnpcny fn inspdio,
<br /> pplieni or AE€nl siere(uE
<br />UNDEB GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Buildinq Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarifier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Pipinq
<br />Roof Drain
<br />Tub/Shower Test
<br />Rouqh Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Main Drain/Pool Pipinq
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Gas Service
<br />Water Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />Rough Plumbing
<br />Final Gas Test
<br />Meler Release
<br />FINAL l0/'lt/t9 i uqv
<br />Notes, Remarks, Etc.
<br />ID/SIG.
<br />..,,^",". 12r?t<,,n-
<br />trnd(ri Addr.$'
<br />*-, q.cy'l
<br />Miscellaneous
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