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APPROVALS DATE ID/SIG.COMMENTS ()wNER Btr -Dt)lr DELCARATl()N
<br />I hcrchy aliirn trndcr Nnalry oi pcrjry rhd I nm c\crnpr linn rh! Conrrrnr! I iccnsc tiw n, rh. folk)wirre tca$n (Scc 70ll 5
<br />&sincsr od PmLsn'n c('dc)r Ary Ciry or C.u y qhich rcqrirc\ r tcrhr io .on{tu.r, rlrcr. nntn,v.. dcnrolish nr r.nJn nny
<br />{tucrrrc- priort' irr i\sor'rc. al\o tuqutc\ lhu ntfli.dr to \u.h p.nnit r. tilc r sitncJ ldcmcN lhrr l.d or shc i\ licdi\cd nr'surir
<br />rolhc nn,vnnnr of lh. Corrrictr \ l-i..trscd l:* (Chrtrcr(). (inn tncnr! wnh Sc.rn 70(x) ol l)]vision 3.frhc llrsinc$ rod
<br />Pfurc\non\ Codc r or rhnr l[ or shc i\ cxcDrlr rh+rcioD o rlrchtriritrrhcrllcgcncrcDprion Anyrn,hrioiufSc.rt{70315iylny
<br />rfpli.anr lo! a p.nnir $hjccls rhc rpplicm! t, acililprrulrroinor mom thr nvc hutrdrcddoUus rSstro)
<br />-1.
<br />I osrc,6l $c l,Ep.rly. tr my.nploye! wirh sr8.s 8 llri sk.otrpcrstion. *iU &' lL {dk &n rlt srnde ir mr
<br />lnrcnd or or.rcd for $L (SE ?044, Blsimss and P,lfc$ions Codq Thc Conracroii Lian.e kw des .ol !r,!ly Io d o*ftr of
<br />rhc Iolcny *ho hrilds o, inpbws ttrNn, dd who de3 such md( him..ll or hcRlf or lhrlsn tis d hr o*n enplorca.
<br />lmlAcdrMr soch in{mrcmnls d br Lr.n&d orofrcEd fo. sl,lf. hokh( the hriUin3 or irpmEmd h eld wilhh onc FU
<br />olonplcriotr tlE olxffi Buibc. will hsr rlE hids ofPDvinS tlEr h or slE did ml hlu or iigroh dE poFry fo. tE pu4Ds of
<br />-1.
<br />!s owrcr of thc ,,rFny, am cxclusiEly contErins eirh lic.tr{d co.ua.n,R l. or3rod trE prcjocl (Sc. 7044. Btsms
<br />sn ADftsiim Code Thc Conlmtols Lic.nk L.* des mi rpply lo an owncr ofrrclcny vho blilds or inpows lnct&n,
<br />rtrd wh. sntBh for slch Imirrs *irh a Conttulo(s) liccn*d p!r!@i ro the Conlrocld s lj...sc L"s).
<br />I am.xcm undcr Scdion , A. & P.C.lorttis Ea.n.
<br />tll)atrD&1.c!]llfENtarloN
<br />DICI.Af,AUqN
<br />I hci.r,y,mr und.. pcnulryolpdFryo.cof lhc rollowine d.clnn'ions:
<br />lrHtr (ixlc.larrhr p!rinriun.cutrhc \o'k ntr $hi.hrh. n.irnir n i\\trd
<br />I havc nd will mainrain worlcrt compensatirn irsumncc, as Eqlned hy Sccr ion 3?U) of lhc l-lbor Codc. ior rh. p.rfmMRc of
<br />My vo-rt B comp.ns.tion insurare ceir and polic, nudb.r @
<br />-l
<br />anily firt in lh. FrformRc of lhc,orl lor vhi.h lhis lcrmil is iss!.d, l.hru nor.nploy any p.6on in my nMtur
<br />$ ar ro bc@e iuhjccr ro rhc s6,tcN omFnsli.n la*s o( Cilifomia. ed aB@ lh,l if I should h.tom slbi(l lo tu
<br />so*6 onqE.sarion Imvhjons of S.dion 3700 ol $. Litu C'ode, I shall, fonh*ilh coq,ly wilh thoe prcvirion...
<br />WARNING: FailuE lo suE porkcs onp.nsalion covcEsc is lnla*ful. Md rhall subrri d cnploycr lo simjnal lEultir lnd
<br />to on. hundrcd rhousnd dollm ($l0().(x)O). in addirion lo rh.6n of ion, daflgcs as trolidcd lor rh.
<br />krn 30?6 of rhc Latrr Codc, inrcEsl ud arromy\ fes-22-ta
<br />I h.r.h, sflirn und.r Ic60lly of p.rjury lhll I !m lianst undc [Jrcr 9 (.nrtunciDg wirh Scoion 7mO] ofDivhiotr 3
<br />of rlr Busi*ss ond Prufcr*ionr Cod.. .rn my lhcnsc ir{ i. tull forc dd clIst.
<br />1q672
<br />-\
<br />g)NuaucuoNtENDlG-aGENct
<br />I hcrcby lffirn lido Fnalry or p.rjury rhd lh.r k a s.cfl.rbn lc.din8 .gcrcy for lhc rErfolffi ol rh. s.l ror whih lhh Fmn n
<br />hs!.d (Se. 309?. Civ. C.)
<br />AIELICAII.DECIIXAIIQ!
<br />I llEty lnm undn pcn.Xy or Frjury o.. ol rhc following dc.ldalion.l
<br />Dcmlirion Prnirs-Ash.sos NotifEariotr tucsl Rcsularions (Tirlc rl(r, P,n6)
<br />Rcquircd L!trcr oi Norilicolior
<br />-l
<br />enilrrhat rhc lc{cralrcslllliof rcslrding aslrrros Enx,lrlar..or amlicdhlc ro rhhtmicl.
<br />I.diryfiar I htrv. r.d lhis .l,plicarion n sr,rerhar rnc otrve inform0rion n c.md I asrftroomplywirh allCilyand Cou.ly
<br />ordinaftcMnd srlrc l,ws rcLrihg lo building consircrion. a ofrhis Cny ud Couory{o cnrd upon tE
<br />stolc ru"r ioncd Dmncny lu inspecrion
<br />>lPrcurorAe@rskEruE:
<br />\ P.mlie En. (prinl) .
<br />D.'",7:23-\fi'
<br />UNDER GBOUND
<br />Waste & Vent
<br />WaterUnder f loor
<br />Gas-Underfloor
<br />Buildinq Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarif ier
<br />Waste & Vent
<br />Water Pipinq
<br />Gas Piping
<br />Roof Drain
<br />Rough Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />lVIain 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 />Rough Plumbinq
<br />Final Gas Test
<br />7lz{,lp -4z{rs )
<br />Notes, Remarks, Etc.
<br />I
<br />PLUMBING.INSPECTOR RECORD
<br />7-t-F,,
<br />I!n&r', Ad.lrc$'
<br />-
<br />TOP OUT
<br />Tub/Shower Test
<br />Gas Service
<br />Back Flow Device
<br />Meter Release
<br />FINAL
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