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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUIIDEI DELCARATION
<br />I ncrchy lmrm undcr p.n lry of p.rjury lhar I m crctrq,t liom rh. Conu&rm Lhcnc ks fo. rlE folowing Elsn (Se.7011.5
<br />B!sin*. dd Prcfc$hn Code): tuy Ciry or Couory shhh r{uiB! a p6nt to otrglrucl. alld. intmt, &mtish o. no.ir u,
<br />!rrud@. Jrbr ro irs i$uaN. aL{ rcq.ircs ttE !t plianr for such Fmir ro fLI€ , sisn { sla&mfl $.t lE o, rlE is liers.d plNrrl
<br />ro rlt Fovisio.s of IE Cont@m,'r Lice.*d trw (Chatlc, 9. ConmEing sith S.clion ?m0 of Division 3 of dE BBincs ud
<br />Pnrfc$ionr Co.!c) or rhd h. o. she h.x.npl fi.rcnom rd $e hdrt aor fi. slk8cd cr.n!,lion. Ary violilion ofSerbn ?011.5 by rny
<br />aplliconr f.r ! IErmir subj.ck rfic amlicant h s civil l).n!lry of tur mrc rhln firc hundrcd dollE. (t50.J),
<br />_1. r\ osNrolihc prcFnr-(tr 1ydnlrloyccs $irhwrE.\ rs rhon v,tco rtrctrsdintr. rilldo 11[qork mdrh:(nrurc N n
<br />inrcfrl.rl orollarrd ntr sb rS.r r0l-1. BDsircs\lna l'roLsriuNC,x]c: llt (-d x'ctn \ l.iccn\c l:$dod not tl,ttyk'0n.sn$ol
<br />rhcpni|rny ah, hx ild\ or ir{tr(,rlls!\[. md tr h, de\ {rh }u* hnn!.ll or icrc li or lh.ouAh his or h$ oen. Dloycus,
<br />ofcon{ldi,n. rhi Owncr Bur*l$ qillhr\c llr burdun oflnnirS rlrrlE or $c d nol huildor irFrartur^ll,{ny forrh.N{n{ol
<br />-1.
<br />0s ownn ol rh. I,oFny. am crchsiv.ly conrrerinB *irh liensd .onrndn6 t. 6n{od rlE amjcd (Se. 7(114, Busimrr
<br />dnd P&6:ssi.n Code lhc Crnradors LEcnsc L.w doc{ nol apply ro on owncr ot,rroFcny *ho huitds or iftrrolcs rhcrmn,
<br />and who conrmrs for such pmirts *ith ! Contflcro(s) liccned pusu.r ro thc Coni mrors Lkcn* tiw).
<br />I rh.rrnrnr un,l.r Sccrr)
<br />III8trEBS:IOMTEIIAIION
<br />DECI.AXAIION
<br />I hcreby a flirm u nder Fnalr, 6f Friury onc of lhc fol lowinB delaEl io tr s
<br />l.nhtr (i .. iirrhc l{rn)rnrnr.ol rM qo* nr\hi.[rl( Jrnnir n isurd
<br />_l hNrc a.d sill minGin worlc*i ompcnFslh. insuEmc. re r.quiEn by Setion 3700 of llt hbor Cddc, fo. rtc Frfomrc of
<br />thc *o* tor whth rhi! pcmit is irskd. My *trtm oml,.Nlion insum onio dd Pli.y numbcr ee:
<br />-l
<br />enify rhd in rlE Frformrc of rhc work [or ehthrhis pcrnn ii i3s!.d, I $!l mr.nrpLysny pcMn ir !try nanNr
<br />so a. ro li..oft slnj..r ro rhc worlcB omp.malion kws of Califomia and aEEc lhil if I sholld bc.oft subicr ro rtr
<br />wort6 omtcnsarion pmvlrions ol S.cio. lTm of rE t$o. CeL. l 3lEll. fonhwilh otr{,ly vilh lno$ lovhions..
<br />WARNINCT Failurc l. *curc *ort s mmrcnsolion cov$.g. is unk*tul. a.d shall {bif,l !n.rnploFr ro ainiml trcNltts and
<br />civil lind ut ro orc hundrcd rhouslnd dolhs (!100,000), in lddilion lo lhc co$ ol.on!..rarioo. dtmS$ as plolid.d tu thc
<br />Sftrion 1076.frhc l-nhor C'odc. ir crcslotrd ltlormy s lccs
<br />n*. 9-\t{-\E noru*,,
<br />DICIdEAIION
<br />I hcrchy amrnundcr nculryotpcrjurr rhr I un ri.cn*{ undo ttuvisiM.tchilrs 9(comrmncinr wirh Sccri[ 70fl)J ofDivision l
<br />of thc Businc$ rfld PmlcssionsCodc- lnl myliccn* is ir tullftnr nlclic.r
<br />Lieecb$i Lk M
<br />q4..'t :!l .-,*n-,
<br />AIIIICANIIIIiCIdXAIION
<br />I rn:hyafrmund.rFnalryof pcrjuryom of rhc follo*in8dcchr ions
<br />Dctrrlnion P.rmir$Asb.sos Nolificalion Fcdcrcl Rcsll ions (Tillc 40- P..i6)
<br />-Rcquircd
<br />t rlcroiNdifrnrion
<br />_l ccdify lhar rh. fc{hrll ,cglhrior3 EB{di.8 !$.srd ,.mv0l m .o! epliclbb ro rhi{ lbixr.
<br />-l
<br />ed ily rhar I havc Erd rhis rpplkslion ud sl,lc lhd tlE ohorc infolrulhn ir sGl I tsxe 16.o.dy unh aI City.nd Counly
<br />ordinlnc.s ard Slarc tlws elrri.g l. b'rildirg .onsldclion. .nd ncrcby lurh.rir rcr.eihlivc$ nf lhir Cny and Counly lo cnlet lron dE
<br />ntxrvc trrnii,io.i pDrnyntr
<br /> lpliff l tr.,\arntSit lu
<br />-,
<br />€u,.
<br />q-.t-\t
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under lloor
<br />Gas-Underfloor
<br />Buildinq Sewer
<br />Area./Storm Drain
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Pipinq
<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 />Miscellaneous
<br />Water Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />Bouqh Plumbing 4ln rB 'I lt rr9 rl':,/r/
<br />Final Gas Test I U
<br />Meter Release )
<br />FINAL tR ?,wrtwNA 7?t )UINotes, Remarks, Etc I
<br />Poli.t Nunhn
<br />-EiniE"
<br />-
<br />CONSIBIT]UONIENDIIGiGENS
<br />I hcrch! afin undcr rEnlh, oa tdjury rhd rh.E h r .onnrudi,n bndin8 a8cRy lor lhc lcrfolrurce ol rhc "br* r.r whi.h lhh Frn l h
<br />issucd lse 1097.Ci!. C )
<br />trtulcr'(Ndm _
<br />L.ndcli Aft*
<br />-
<br />Roof Drain
<br />Gas Service
<br />lt {
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