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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',