|
APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDTR DI'LCARATION
<br />I hcrcby aflnnr nndcr !.n.hy of lcrjurt thar I m excmrr rhm lhc Conlft.n n l,iccn\c ljw r{tr rk tollosin8 rca{ 1sc..?011.5
<br />Bu\incss rnd Prolc$ion Gnc): Any Cir, or Counry which rcquirc\ a pcdi' b .o!{ru.r. rlrd. in1l)mvc, dcnn'lish or a|[n roy
<br />{tu.r!rc. pri{trro irs i\\rnK_c. also rc+ncs rhc lpplicMr f.r \uchFnnir ro filcn {8ncd {rrc!tunt rhd hcor\hc is liccn\cd pursu t
<br />ro llrc pmvhiotr\ of ilE Conktrcrois Liccnscd tiw (Ch,prcr 9. ComnNncins tr irh sccrion Tlxx) or Divin,n I ol thc Busirc{\ rnd
<br />l'n'fcsnrnr Co{lcrorrhrr lE or\hc i\ rkmpr rhcrcfinn md rhc hr\i\ r(tr ilr rlkgcd.rcnuio. AnyriolalionolScdionTl).ll5hro,
<br />{'pli.ad nn o pcnnit subjccls rlE 0ptli.rtrrro rcivilt'cnrlryurnor nxrflhii fivc hundrcddollffi (35(xl)
<br />_1. a ownc, df ihc ,roFrlr. or oy cq,loye3 wnh wr8.s $ lnch sh @nFnsation. wil do t}l m* &d dc srtut@ it ml
<br />intdxk or oit rcd ftr sL (Ss.70a4. Busircss Dd Pmfcssiors Code: Ttf, C.nlrutor's Lic.r* Llw d@s rcr ry,,y lo e osE of
<br />rhc F!.ny wh. boilds or iitdB dEtun. !d *lE &B sh tu* himlf or h.elf or thmugl ha! or h6 own.oplorrcs,
<br />lroridcd rhrr slch inFnEmnrs @ mr hci<krl oroftrd for sL. lf. lhkB. dE ldaldi.g or insorcmnr ii $U wnhin o@ ra
<br />of@i!)trii6.. d. Ower Buittcr piU har r,r h!d.n of t'DtinS dEr t or slE di.lDr ttrild or intEf dr p,opqry for tlr !o{be 6(
<br />I, a .sncr of rhc pDp.ny, m cxdxsivcly conta.'in8 wi'h lic.!s.d mnxdm lo mnslruct llE pR+.1 {Scc. ?O14. Bu1u4,
<br />arn hDfssion Codc: Thc Conklcroas Licctrse t2w dcs nor apply b e o*ncr of popcny who builds or improhs rhcrcon,
<br />ed eh, @ntm.ls for such !ruicrs *ilh a Conhcro(9 liccn$d ,,Bunr ro rh. C.mrelols Lien* t *).
<br />I amcrcnrfl utuldr S(rnr
<br />Lrrr
<br />uQaf,Exl:coMtBrarlo!
<br />D&CLABAUA!
<br />I h.Eby aflim u!.tcr lcmly of perjury oft or lhc toll6winS d6lrmio.s:
<br />-l
<br />havc !d will nEi(rin a CcnifNrlc of co.scrl 1,, sclf.lNurc for wor &cs' qnnpcnsdiotr. us ln,v cd nn 6y Strr ion :r70o .f rtu
<br />Lintr Orlc. for lhc pcrfomEnN of lhc wort lor whth rhc t cimir is is\u.J.
<br />_l har and will mainhin worlcr .6dt .s.rion iniuramc. as rcqdrcd by Sccl ion .l?{D ol rhc til,or Codc. tor lhc pcrfomncc of
<br />thc sort lor shkh lhir pdmn is hsdl. My eork.* on{xmrion in{r8m ffhr 3rd policy nunbcr ac:faa.
<br />p.'"y." b",,. tpr-/LpL ??UA 5o E^i,"": 412* l-*-
<br />_l eaily ihll in $c F,rornrnm ofth. worr for whi.h $h pcmi ir hsu.d. I shollnol cmploy any peson in any tuntur
<br />$ trs io tEcom suhj.ct to lhc No.t.N'compcnsolion lows ofcllifomia. lnd asN rhol if I .hould h..om subhct ro rlE
<br />*od.sl smFnsarhnrmvGions of Scdion 3700 ofric littr Codc.l shlll. fonh*nh @mply withlho. pmrhions.
<br />WARNING: Fdilurc ro *.urc *olkcF comp.ns0rhn covcnSc is trnlnN,nl. and shall sul+cr oi cnplorer ro sinind Ftuhi.r Md
<br />civil nncs up ro o.c hundrcd rhousnd dollarr ($|(x).fiD). in addiron ro thc cost ofcomFnsaiion. drrugcs !s rtuvidcd toi lhc
<br />Scdion 1076 of rhc Labor Cod.. inld.sl od anomy s fccs
<br />,"", " I'l t4/ t9.'n'I
<br />l)f,llzllrlllQl
<br />I lErby alfim undcrycBlry of perhry $ar I m lieN.n !.dd t mvi.ion of C-tEptd 9 (onmncing wnh SElt n 7000) of Divhion 3
<br />of thc Busims ad Prefcalioni Co<lc. ard my lkc@ is in tull foN &d ctfel
<br />{
<br />o"", A//v / /* coor-"ro.\A-
<br />CANSIAII:IIaN.LIN]INTi.A1iENII
<br />I h,rcby amrfl u crtrnilrroipcrjurrrh.tIhc.cisoon{rucrhtrlcndineryercyrorrhcI,crao'nnkcorrh.*oiklorqhichrhi\P.rmin
<br />issucd(sft ltD7. civ. c )
<br />affuc NfDEct ASlrlolt
<br />I h6tby otrtrn und$ p.nohyofpcrjuryorc of lnc lollowinA dcclealions:
<br />Dcnrolirion PcrmirlAsh.(os Norification Fcdcnl R.Buhrio (Titlc 40. Pln6)
<br />Rcqutcd Ln.r oa NdifK.rion
<br />t ccnilvrhd r\c rcdckl r clulr,nn, rlddrnq ,\hcdo. rrmvJl d nor'ml(!bk h 'hr
<br />pFi$.
<br />Llfi, *, , t* -, ,". snnrrdbn snd {!,c rhr h. stnvc inrorrorion is corer. I lsd ro comdy sirh ult ciry &d counr,
<br />odinarcs ar<l Shl. Liws relding r. buildine .onirudion. a.d hcEh, .urhorizc rcrc*nt{ivcs of lhn Cny and Couniy ro ..ts upon tlr
<br />lbovc mtrlioncd pmFny lor irspcdi{,nturyrcs
<br />Dsr.:,: --
<br />UNDER GROUND
<br />Waste & Vent 7 (r(/(,16il
<br />Water-Under f loor
<br />Gas-Underfloor
<br />Building Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<br />I . o<i:<@
<br />Water Piping lv t6lv0 \r,- (Ir-"
<br />Gas Piping
<br />Roof Drain
<br />.r^^<rdV >)
<br />Rouqh Water Heater OJ
<br />14/
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Main Drain/Pool Pipinq
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Gas Service vltt .LrnXtt,tt*A:I lnt T VAt4nc)-fr)
<br />Water Service U ur
<br />Lawn Sprinl.le+.
<br />Sanitary.rfewe*/Cap 'aw€"c ze)
<br />Back FloVfevice U {
<br />I
<br />Rough Plumbing le V |a'li b..\r.-€,h ,8,)
<br />Final Gas Test t Ir u\
<br />Meter Release
<br />FINAL 1 flA'we*l z'ss)
<br />Notes, Remarks, Etc.il
<br />PLUMBING-INSPECTOR RECORD
<br />t9
<br />Waste & Vent
<br />b,l'Tub/Shower Test
<br />J)
<br />?,tt4',
|