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\PLUMBING.INSPECTOR BECORD
<br />APPROVALS DATE rD/srG.GOMMENTS OWNI]R BUII,DER DELCAIA'N()N
<br />I hclcby rltm u.dcr Nnalr, of lcrjury rhrl I cxcnu riorn rhc cotrtr.k J Liccnsc ljw nn rhc iollorin8 rcrsn (Scc 70ll 5
<br />Ausincss 0tu Prolc\sn'n (tdc) ny City or CouNy w[ic[ rcquncs . rflnil ro consrrud. ills. inl'rolc. dcmni\h .r 'crln u,
<br />srucrurc. prior lo irs issuancc. llso rcqlncsrhc amlic l r'or such !f,rnirto lik 3 \i8ncd (lremnr rhtrr ll or\hc i\ lrrn\cd pr^arnr
<br />b rhc flovi\nnN olrtE Conkfloi\ Licctrsed li* (ch.rr$ 9, cl)mnrNing snh sccrion 7000 of Divisnr..l ol rhc Btrsinr\\ nnd
<br />Ptufc\\ion\ Cod.) or rh3r hcorshc i\.kc rrrrhcrr,i.Dan,lrhchr\islorrhc!llc8cdcxcnrpri.n AnyviolarionorSccrionT0ll5 hya y
<br />.pllicanr lnru nci,nn \uhjatsrhc rmli.an' h n .ivn pc.nk! .r ior m,c rhrn llvc hundicddollars rs5(x)).
<br />_1. as owner of rh€ I,DFdy. or iy crDloy*s qirn *agcs as rhcn sk coryEnsrion. *ill do th. wrk aid llE irrEt@ ir mr
<br />iit nd.n or olf.rcd fo, $& (Se.7044. B$incai and Profesio.s Codc Th. Conh.roCa Uccns kw des .or ,Iply ro e owmr of
<br />llt pmFfly v,x, builds tr inpoa thcmi, ud who de3 scn sll( hins.lf or bcisclf or lhmugh hh or h6 own cm!hlr*.
<br />r,ruvi(M lh,r 3uch i,lmwftdrm mr i.rddcdorofcrcd forsh.ll howcw. tnc bildins or irplftmnl hsldvirhin (rur
<br />ot@rmbrao rh. O*dr Buikb $ill hlt dE t{dcn of !rcvin8 lhd h. or sh. dil mr }Dild or in{,mw lnc po!6ly for tlE purlbs of
<br />-1.
<br />as ow.cr oI thc pmpcrry. !o .xcluii{.I, .onrturing wirh licen*d co.rracro. ro on{rucr rlE pmi$ (Sc. 7014. Busim$
<br />ard Eaftssion Codc: Thc Contactol s Lic.nrc kq d@s mr lptly ro !n own.r of prop.ny who builds or impmvcs thcreon,and {ho co ra.6 ror such lmjccB wnh a Conrr,tu(r) liccn$d plrunr b rhc Coora.rq\ LEcnk Li*).
<br />UABESS:IIIMPEIIAIIITA
<br />DECI.Af,AJUON
<br />I tcrc6, am,m lndcr pcMuy of r.rjury o* of rhc followin8 delaElhai:
<br />-lharc
<br />Md trillminra o Ccrrlicarc oaA,nsnr lo Sclf-lnsurc for workcr' .onwnsrr bn- rs Dmvidcd tn, h,Ss.'ri(,i.l?(x) ofrhc
<br />L3txtr (_o{c- ior lhc psloi,roncc of lhc work rbr *hich rlr ,)mit i\ ksucd
<br />I havc trnd *ill mlinrain worle.a conf.nr,lbn iftu,skc. ss Equtcd by Seti,n :1700 or rhc tlho, C.dr, for lh. p.rlormnc. of
<br />rhc eo.t f.r shhh rhh Fmn i{ hsxcd. My work6 @dpcnsurion in.uEnce.n* d{ policy.umbcr m:
<br />-l
<br />ccnily rhrr in rhc pcrfonrrn . ofrh. work for whih rtir Frmir is issucd. I shall not.nployrn! pcmon in an, ru.ncr$ db tEo,nr suhjccr ro rh. *ortcn compcn\dion luss ofcoliforni!. and lEE rhar ial should tE{om \lhrcsl ro ttc
<br />wulkcn.ontn\arn,ntn,visions.rS.cri6nlT0OofrhcljlnrCodc,lshall.fonhwnh..mdy*iihrh.epm!iri.ns..
<br />WARNINC: Failur. lo suE workeE omp.nsrk)I .owEB. is un!.wiil. $d shall slb,cd e c,phrlr lo dimiMl |aelras.rtd
<br />civil fincs !p ro onc hhdr.d rhoo$nd dollm ($100.0m). in .ddirio. ro rhc osr of onFns.don, dles.s as ooritcd lor lh.
<br />Sdion 1076 ofrhc bhor Codc. inr.rcsl ud anomy! lcs
<br />LII;ENIEO.CANIAASIAA
<br />DECI AIIAT(i]{
<br />I h.rhy rfliii!.dcr pcnllryorFrj!ry tbdt I m li.cn*d u.dcr pr,!i\i.n orchrprr9 (conrmmi.S wnh s.crion 7ux)) ol'Divisn'n ]
<br />ot rhc Dusirc$ !n.l Profc$trn\ Cod., !d my liccns is in full lbrc! uxj cfrcr
<br />Corlo.lo.r_
<br />caNsr&]!: 0NtiNIIxclGE!(r
<br />I hcrhy rllnm undcr prnrl(y.l t^-.rurylhrr rhcrc i\ r.oNru.rim lcBlin! r8.ndy k{ rhc pdrlarmrn.c ol rtu s.rl1,, I hkh rhn Itrn,ir n
<br />i!{rc(l(Sc. 1097. Civ C )
<br />AITLICINLDE.CI"AB{IION
<br />I lurhy jnnund$ pctrrlry oft,crjury otrc olrtu lnlbwnr! dc.ld tun\:
<br />D.nri lir i(r Pcrmir\ slr\ro\ Nori6ur ion FcdcBl RcguL ions r-l irlc J(J. Pfi 6)
<br />Rcquircd Lc(.rolNorilLdn r
<br />-l
<br />ccnify thlt rhc fcdcrat rc8llatiotrs Ega,{itr8 ash.sros nmval m mr apt li.at k ro rhn Inj.{r
<br />odirrn.cs 3trd Shlcl-rsa rcldilr3t' huildingcon(rucrtnr rnd hcrchyndlFrtc rcprc{nrxlivc\ of(hi\ ( iryrD.tCornryk'.ir.r uE)nrhc
<br />at$c nrnrn)ncd pn'Fny hr nrlpc(riotrlurtRr
<br />Appli.nrl or Aeerl Sianolu
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Building Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarilier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Pipinq
<br />Roof Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Main Drain/Pool Pipino
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />Rough Plumbing
<br />Final Gas Test
<br />Meter Release 6)
<br />7,f,t -id da€tc,)fd?
<br />Notes Remarks , Etc.
<br />d4.a,_tz '/z-r d,/;- I a1/tl
<br />Gas Service
<br />Water Service
<br />FINAL
<br />n -. l; 4a,u,*,-rl i /1A*/,.,t-Lr----.-
<br />/tV,/B Lo+ ,Z-zil
<br />-l
<br />Mcx€mpl undcrSalion-. B. & P.C. forrhisrcasor
<br />Dote Ovn.r
<br />Li*N. Cbs: Liccns Nubdi
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<br />L.nder'r Nrm _
<br />I ctr,1./. AdJrcs
<br />I
<br />tl
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