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APPROVALS DATE ID/SIG.COMMENTS OWNEf, BUILDER DELCAtrAIION
<br />I tcrcby amrm lndr Frulry of pcrjory rhd I m .rcd filn rh. Contrdm'Licc!.. Lrw for llE followine E.sn (Se.?011.5
<br />Blsinc$ and ft.a.sshn Codc)r Any Ciry or Couory which rcquiB a Fdn lo onnn cr. ,lld. im0rot. &mlhh or rcp.n rny
<br />nrud@. p.hr ro irr is3uMcc. .l$ ftguircs lnc lPplicul for sn pcmi lo fik , .i8md sltlemnl lh.t lE or slt n liat*d PoNsi
<br />ro rhc pNvhions of rlE Co eroCs Liensd tlv (Ctupi( 9, Co,tmmin8 *ilh Selion 7000 of Divisio. 3 ol thc Ausin.sr .td
<br />Pof.sioN Cod.) or rhtl lE r ilE i3 dctr$ dE c&or..d rlr t$t for llE dE8.d cr.nption. Any vhlrlion of SEli,n ?01t.5 by my
<br />applicafl ror atcmn 3ubj6k lhc lrplha.r io s civil pcDlry of nor mF rho rivc hudrcd dolL$ (!500).
<br />-1,
<br />os ovrcr of th. prct*ny. or my cmployes {irh w.8cs s rhcn sb ompcnsrtion. *ill do th. wdl od itc ddw n nol
<br />inlcd.d o. onced for sl. (Se.704.4. Blsimss ond Itlfcsrions Codc, The C.fldtr r Lisn$ ljw &B ml q,ply lo o ownd of
<br />rhc pDpcr,y sho hildr or inqmG llEEn..,xl who dG *n s himclf o, hcEllor ihFu8! his or hd om.nplor€cs.
<br />lmvi.l.d lhrr such inlmvwds e mr hrdrLd d ofi.rd f6r $L, l[ lbkE lh. t{ilCins m nlomwtu ir sld widin om F{
<br />ofo'rTbion. tlr O*mr Buitlq *i! hlh thc hrd.n oaFlvin8 lh"l lE or slE dij mt hild or inqJNE otc ptuFry fm tn. Purpos of
<br />l. $ o*re. or rh. trop.ny. !m cxclusirly srrr*ring wnn liccnsd .onrk'or b onsrud lhc ,,!jEt (Sr. 71x4. Brin*r
<br />ud Pmfdris Cod. I Tha Contaclor's Liccnre Lsw docs ml opply lo an o*rcr of Doncny who builds or imProics lhcrcot.
<br />and who onrtrrs for sftt lmjeG *irh a Co eto(d ltcnkd pB@l roih.Conlrdols Lic.n* Liq).
<br />I mcrcmDr unds SrcrDn ,B & PC. torrhn m.son.
<br />llo8trEBL:go!{fjusa110N
<br />DIgI,ABAIII]N
<br />I hcrcby difim !.dcr ,cnalrr of tErjury orc ol thc tuUosins de.lmlions:
<br />-l
<br />hav. .r'd will mintlin a Ccrrifr.rr of Con* lo S.r lnsuE tor s.t.^' omFnslion. as Fovidcd for by Sstion 3?dl of lh.
<br />t,br Cod., ftr rtr Frftrmm. of th. Pod( for which lh€ pcrmir n i.s!ed.
<br />-l h.vc ud will naimsin workB cooFnsrtion imume . $ EAUird by Sdion 1700 of rlx Llbor C.dc, for llE !.rfo,mre of
<br />whkh'hi\ ncmr n ^o.d MX"orkds. mmFnkri.n in\urm camr and Inlrynufrhfl m
<br />il-n+L fi"nA
<br />q2t t3S7 t'1 S'21, . l X
<br />-l
<br />cenily rhar in lhc F.formmc of lhc wort lor stichlnis p(rmil ir iqsucd.l shtll not.nll,loy any I,cMn inrnynmm,
<br />$ as ro hcs'E subjcct to thc eortc6 ompcnrNrion laws or Cnlifornia. lnd a8rcc thlr if I snolB t .o@ $bjd b
<br />'lEwolkcd smpcnslrion F,vhn,nr oa s6rion :1700 ofuhc Lrbor Codc, I sholl. fonh*irh .ooply wirh rrh* pmvtions..
<br />WARNING: F lurc ro surc vorkcr' ompensarion covctasc ii lnlawhrl, 0nd shall rubi€t on cmplotlr lo ainintrl Ftuxics and
<br />civil arcs up ro om hundrcd rhou$d dolle ($100.000). i. a&ilio.lo 6rrion. d.tugcs {s povu.n tor lhc
<br />s..r ion t0?6 of rhc I rnr C.ic. inrcred and ,toft tr:'W
<br />s.zq. 16
<br />DISASAIIIIN
<br />, hcrb, affiro !nd.. p..,h, or p.rjury rhar I om li(nst undcr lbvision of Chlprfi , (connEmi.8 eith Sccrion Il0O) of Divi$n l
<br />of lhc Busimss and Pmlcssions Co&, E d ny lkcn* h i, fulltnra uxl cf(l.
<br />lun936l"-*.o*, B Liccnsc Numhcr
<br />IIJASIAU TOEI,EIDINCT$INCI
<br />I hcrchy rflirnrunJdr F lry.i tf,rjurr lhlt Ihsc is . coNrnd ion lcndirs rscmy ntr rh. P$lonunc. or lhc work rbr which rhis lrnnir k
<br />i$ucd rs.c 3097. Civ. C )
<br />AIII.ICANIDEI;IABAIION
<br />liu$ydrhnhdd Iftrrlry oifcrjury onc olrhc lollo$inE dcchmln,ns:
<br />Dc.nnirn,n Pcn rs sl'.{os Norincarion F.dcdl RcBuldions (Tirlc,10. ?an6)
<br />-R.qutcd
<br />lrrrcr ol Nor ilic,rio'
<br />-l
<br />.cdiry rh,r rhc acdcral rcBlltrtions EsddinB ostEsros Emval m nor +plk,bk h lhis pmlc.l.
<br />laliccni8 rhar I h.vc rcld rhis applknrion
<br />'nd
<br />sotc rhd rhc |trvc informrion isc.Br. 146 h..mnlyuirh rlr ciry,tul coumy
<br />ordinucc\ lnd Srarc ljwr 6larin8 ro buildnr8con$ruclion. axl
<br />ahrve m n,ncd porrcn, tu i.s
<br />I t€,
<br />thn Ciryalld Cou t ro cnrs upon rh.
<br />""," {-z\'lY
<br />UNDER GBOUND
<br />Water-Under lloor
<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 />Rouoh Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Main Drain/Pool Pipinq
<br />Fill Line/Back Flow
<br />Miscellaneous
<br />Water Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />Rough Plumbinq dzo[t9 /u,s/H)
<br />Final Gas Test t
<br />Meter Release
<br />FINAL o/'tb /l'6 )DI'b
<br />Notes, Remarks, Etc
<br />PLUMBING.INSPECTOR RECORD
<br />Waste & Vent
<br />Tub/Shower Test
<br />Pool Heater/Gas Line
<br />Gas Service
<br />o.", lS.z{.t6 c-,'-r* A(c
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