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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER tt('tI,DER DI]LCARATION
<br />I lRmht !fl, n utrd.! Ftrrlly oI p.rjrry rhd I n cr.'qr fnnn rhc Conlrrctor' l,ic.n\c Lr$ f,n rhc ftnhwir8 rcrv,n lsc. /0.rl5
<br />tsusircs\ i Prnt{ion C{xlc): Any cny or Counrt whi.[ rcqutcs i pcnnir k, .onirucl. ulrcr. imPr]!c. drm.l$ or rNt rnt
<br />incrurc,Iritrro irs issuin.c. oko rcqutc\ thc applicanr f{, \!ch'Imir tu liLr sisrEd {arclL-ir rhrr }ror\hc n liccnsed pur\urnr
<br />lo Ihc povi\tns ol rltr Coirrr.ktrt Li.cr\en tnq (C[iflcr 9. Connncnciir ,irh Sc.rion 7000 ot Divisidn .] ot rhc Busnr!\ rnl
<br />Prorasxion\Codc)or rhi hcorrle is crcnrfl rlrcrcfiorMd rhc b!ri\ tirrrhc rllrtcd crcnrllion. Anyvnnlrn ol scctin T03l 5h!rnr"
<br />!pplicrtrr [itr]!c'nrir \ubiNrs(h. rnnlicanln,0civil!.nrliyotnorntmrh.tr llvc hu,rdrc.ldolhs (S5u)
<br />-1,
<br />!s owftr of rhc FoFny. or my crnployes wilh wrSps !r lll.t sL onncnr.It .. will tlo lh. *ut sd dE strui@ is ml
<br />hrcid.n or ofr.i.i lor sh (Se.?0d4. Ausift$ and Prolcsiions Codq Th. C.ntlclols LicenB Lrw docr Ni aPply to di owr of
<br />llrcpmpsty wt5 bliktror i'rt,irBilr@ ud who.kEs sh mrt hiNlf or h.t*lfot lhDugh his or hcrowncmplor6.
<br />povid.d rh,r Mh in9,orcm s @ mt i'neftled do,rstd for eL. tf. tbkE llE |tihins or i'r!ftwc i! sld vithin orc r@
<br />olonpLrio., dE Ownr Buitld *ill hrw llt hEdH of lmvinB rhd h. o, sh. did mt boild d in toE 0E p6,Elt for lh. luqDs of
<br />-1.
<br />!s .{n( nf rhc r.pcny, trn .tlusitly conracrins {irh li.ensd .oolracloB tL onnod thc |jej(l (Se. 7044. Busims\
<br />o.d ftoh.sbn Codc: Th. Conr@brt Licc.k Law dm! mr rmly h eowrcr of ImFnyvho builds or inPmv.i lhcNn.
<br />ofld qho .o.tt!.rs for such pDjek wnh . CorlEcIo(9 liccnsn !!@fl ro $e Co.lmcrd's Lkcns U*).
<br />-l
<br />am .xcmfl ud.. S*tion.- B, & P.C. to. ttis lwn
<br />ll)8f,8X5:grMf8sArrO!
<br />DEgIA8AIION
<br />I hceby !m,n undcr pc@lly of lsjury orc of lhe iollosinE dcclualjons:
<br />-lhrvc!'rlsillm'nnninrCcnilicricol(on\cnlloScltlr\urci,sork..omPctrlirion.usPx,vAdfdhyS(ri{trr3?0Oolrhcltrlbor Codc- li,r Uc pcd,,utuu olrhc sorr ftr uhich rhc Nn n i\sucd
<br />! hrvc aMwill BinrrinwotkcrlconrFnsariooinruonc.asrcquircdbyScdion:t7morrh.LjborCodc,lorlhcldfonnrn.col
<br />Fmir is irsucd My w6*6s' oqf,nsdiotr insurm ceifi 8ri Ptty mmlE m:
<br />0 r.\. \q.
<br />-l
<br />c.nify rhar h ihc nerfomrcc of tlt so ror wni.h rhir FrnI k issucd, I slEll @l enlloy dy p.Nn in lny nEn6
<br />$ &r r. br€m subicl ro rh. wortdC conp..Biion hvs of Californiq ojd a!tu lh.l if I 3rsuld tEom sbifl l. rh.
<br />workBC omp.nsalior pmvisioos ofsetion 3700 of thc tihr C!dc. I ddl. fonh*irn omply Nith llns PmvisioE..
<br />WARNING Fai,urc ro surc eortc* comFosario. .owng. i! unl,wtul. lnd shlll snbjcl e cmplolEr lo didndl Fnrnis ad
<br />cNil nncs up ro om hundrcd lhou$nd dollm (!loo.mo). in addilhn |o lhc oi ot comp.nsalion. dlmgc$ I J',ovid.d rn rh.
<br />sdion 10?6 ofrhc Lltn code. inrd.{,nd,tormy r fLrs
<br />*,f,lAY 17 ?A 1l no*-,,
<br />Ihrr.b}!firmund.rFnalrlorJrrjurtnmrIrnrliccna\,n cr!('!'\n orChrPrcr,(cotrrnrnciis{irhsccr n7u}r)otDirnon:l
<br />of thr Bu\nrssrnd Pd.lnorNCoJc, t l ry li.cn\c is in tulllbr..JndciT.cr
<br />looflq&
<br />SOIIIAJJqIIANIEIDIIG.ACEE!.:X
<br />I h.Eby affirrn underyci.lry ol pcrjury lhrt lhm is , snslruclhn kidins dg.ncy lor rhc p€rfomrc ol6. wort for whth rhis ncmi n
<br />is.d(se.1097.civ.c).
<br />A.TTLICANIDIiILAXAIII}N
<br />I trnby arlinn undcr |rMhynlp.rjury orc ofrh. followins dcclda'ions
<br />r)cN,ltiotr PcrmirsAshc\ros Norin arn,n F.dciDI Rcguhrions (Tillc40. Pan6l
<br />Rcquie.l L.rrer oa Norifkari(,n
<br />1&1r r*, ** *^,*arpL.rion &d shre oEr dE I lfrcbomplywith{ll Cilyand Coonr,
<br />oilindR-cs Md SIdc tjws rchrina ro hu ililitrg ..niflctiotr ol rhis Cir, End Couniy ro cnrq upon lhc
<br />dtx,vc nMliomd po!.ny for inst€tion
<br />HAY n7 2018lppli(nnl or Ascnl si*ndl
<br />Pemne namc (prinl):
<br />Water-Under floor
<br />Gas-Underfloor
<br />Buildinq Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarifier
<br />TOP OUT
<br />Waste & Vent
<br />Water Pipinq
<br />Gas Piping
<br />Roof Drain
<br />Tub/Shower Test
<br />Rouqh Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Ir/ain Drain/Pool Pipinq
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Gas Service
<br />Water Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />Rough Plumbing {/a )/ta ?--lr-.It-lZriA ,d
<br />Meler Release
<br />F|NAL *.L<S Wh /le >l\?6
<br />Notes, Remarks, Etc.
<br />UNDER GROUND
<br />Waste & Vent
<br />Final Gas Test
<br />-l
<br />ccnify rhdt lh. fcdcEl E8lklions Esu.di.s ost stos rcmvd sc nol a!!li. L lo rhir rmj.(r
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