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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE COMMENTS OWNER DUILDER DELCAIATION
<br />I lrEby am.m u.der Fully of Frjury th8l I m.rcnpl t n lt Conlr&lm Lian$ L3* for llE follo*in8 rcen (S.r.7011.5
<br />Ausincss anl Ptoa.$ion Codc): Aiy Ciry or Cou.ty whi:h rcquircs a Dcmi ro coi$od. alr*. inlt)ovc, &mli.h or Epon dny
<br />srtuctuc, t ior ro irs issude, also rcqlircs llE {ppli.u for such pcmn ro ,ilc a siged srarE.r thar lr or she is liccnsd p!N@l
<br />ro th€ p@vhiotu of d'. Conrrmrols Liedscn bw (Ch,prc. 9. ConBming wirh Scction ?000 of Division 3 of lhc Blrires .nd
<br />Pmfcssions Code) or rhd lE or sl* is cx.trpl rh.Enonlnd tlE blsh aor rlr alkB.d crcnprbtr Anyviolaiio.ofSc.lionT0ll.5hylny
<br />ap?lica foral)cm subj.fls rhc qrplic.fl ro !.ivil t'.tulryotnor mr $ar firc hrnrlr.rl dolrB ($500).
<br />-1.
<br />as osi6 ofrhe topcny. ah.x.lurivclyc.nrrudins wnh liccn€d .olnru.ro$ i. onslruc! lhc Irorcct (Scc.7M4, Busncss
<br />0d PiolL$simCod.r Thc Conrrocrols Liccns. t w d.cs ml rypl, to er owncr of pmlcn, who blilds o. impors rhcrmn,
<br />and who 6.lacrsfors!.hllfoif,t.wnhaC.6ctodOli.cn*dpurrMrbihcCo.rfrctolsLiccnFL!w).
<br />-l
<br />dcrcmpl uido s6rioo- B. & P.C. ror fiis EM!.
<br />Dar.: O*Rr
<br />IAatrEBECAMTJNIAIION
<br />DECI.A8AIION
<br />I hcrcly ,lfirn und$ ttuly of ndjurr o.c .f ih. follo*iog d.cl,nrhn\
<br />-l
<br />h.vc nnd qillfluirrain r CcdiaElrc olConscnr ro Sclt lnsurc aor *ork 6 conFndnrn,.s F,vidcd ror bySelion ll7fi)oirh.
<br />tibor Codc.ln thc l). nrmrccof rhc wolk ror vhich thc psmir i! issucd.
<br />dI havc
<br />'d
<br />w iU nrinrain workcE conpcn\dion insurutuc, as toqun{d hy sccrion l?Oo of the tjbor adc. lor rhe l]crft,n&e c of
<br />rh. *orl aor *hi.h rhn pc..!ir is G\krl My {orksa conf..sarion in\uftncc cdicr ud loliy numbn m
<br />a)t\1D- 4a, r -tA'. t
<br />Jr-9zooq.t 5-- ?- 11
<br />-lenifrlhar
<br />in rhc p.rformmc of lhc wort fd whichlhtpcmit is nsu.n.l sh,ll mr.nploy any FMn in any mnmr
<br />v, 6 ro tE onE srtirr ro rhe sdt6a .otr{t.$raon lu*r 6l Clljlomia. {Id agre rhar if I should bcsft subjel lo llE
<br />wo*qi ompcniar ion pmvirion\ of Scrion 1700 or ihc kbor C.d., I sh,ll. ftnnvnh conDly *ilh thos pmviions.
<br />WARNINC, friturc t, ycud w.rkc* .omten{rn,n crv.nec n unhwful. and sholl subrccl un em0bycr lo cri,nind pcMhic\ und
<br />.ivil linc\ u, b .nc hr6dr.i lh.uund dollds (Slfi),ooo), imddibn k, lhc cosl oi conrI]cnsrion. a ul.r ,1 lrovid.d ror rhc
<br />oi lhc Bu\irc\\ ud f!,lc*i{usCodr. rtrd i,t licriv n i'r full nrcc dtrlcl1c.r
<br />qzrz
<br />o*, -5:-L1-:-!L c.or"ua,'
<br />CO!$AIj(:IION.LDNIIIN(;.ACENCX
<br />I hcrb, uniifl xndd Fn,hrollcrjury th,l ficrc is ! snsruclion b.dinA ascmy nr 0E rst)rroft. orlhj work lor whthrhn rr.lt ir
<br />iss!.d (tuc.:l(r7, Civ. C )
<br />AITLICANLIIiIIAEAIION
<br />I h.n'by dilinn undf p.trr[yoltrrjuryonc ol rhc followin8 dslamri.ns:
<br />Dcnlnii,n Pcrnrih Ashc*o\ Norificarion FcdcrJl Rtaoh bns (Tillc 40. Pd6)
<br />-Requtcd
<br />tdrs of No'ifEBri,)n
<br />lit ccnilt rhor I lElc rcld rhis amlicarion 0r'd \l!tc rhar thc abovc inlonuri.n h.6'trr. I 0grft tosmplywirh allCilyand Counly
<br />ordimrccs lnd Srorc L8ws Elarii8 ro io..8rd hcrcby au horie r.Fcr.oralircr oflhh Cilyond Counlylo cnrcr q,on lh.
<br />at w nEnlioncd,mp.nyfor i
<br />Alpll.rtrl or Asenl SlsEluE D,r.: 5' "n -18
<br />I
<br />Waste & Vent 6/ x /rx .&6,)
<br />Water-Under floor
<br />Gas-Undedloor
<br />Building Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Venl
<br />Water Pipinq
<br />Gas Piping
<br />Roof Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />lvlain 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
<br />Meter Release t
<br />FINAL 7 7-7//Y .-flry|)
<br />Notes, Remarks, Etc. 7-
<br />ID/SIG.
<br />UNDER GROUND
<br />Final Gas Test
<br />-1.
<br />.s owncr of lhc tmFny, or ny .ry,lolEs wilh wtr8.s I lhct $lc onFcnsolion. vill do ltt wk lrl lh. snrnE is rcl
<br />inrcdcd or oficrcd for $lc lSe.?M4. Business lnd PDfcssions Codc Thc C.m.!.t r. Li.cn* tlw ilo.s nol lpply lo an owm. of
<br />rhc pbFny wh6t ikLr or idpmrs llsstr.rn {h. d6Mhmlk hin$lf or hcmlf.r thDu8h his or ns o*n cr{'loyc.s.
<br />prolidcd r,ut such inl,@\(fu'rs G Dr hrcn<tcd o,ofr.En fo, Fb. li noea. dE trildinS or ir+,sEnnr ir eh wilhin or Fe
<br />ofconplclhn. trE OwE Buitl6 will lEe dE hrdcn ol Flvi.g rlEr tc or nr dn ml hild or iqmE rh. p@Fly for llE l,urros oa
<br />Serior 1076 olrhe t borC.dc, inlcEsl.nd romr\
<br />o.r.' 5 21 ' lQ epol,,nt
<br />_l ..niry rhnr lh. tcd@l bguhrnlnr EgaidinB dlBlor nmrd m nor dpt li..bh lo lht pDj.rl
<br />-.2<-,4 w.
<br />.r. \\,eo.?-'t\|
<br />tl
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