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APPROVALS DATE IDiSIG.COMMENTS owNEta BUtLDUta DEt,C,lRAl tON
<br />I hcrcby rllir nndcr Nnrlry of It.rtury rhd I rm cxcnDr lrom rhe G)nhcl{m l.i(n$ taw for rhc n,liNinS rcinnr (Sc(?l).115'
<br />llu\iNs aBl trrote\\iotr Codr) Any Cn, or Cornry which rcqurc\ r Frnnr tu con{o.r, rllcr. inrrnnc. dcnslish .r torrtr rny
<br />itcrur.. prh kJ ns i\{urncc. nl$ r.qlircsrlr lll)flicrtr rbr su.[ pcrlnill{i lilc r \is'td {aicntnr ihd lror shc is liccnsd putsutl
<br />k, rh. pn,ri\i,n,r ol rhc C.ntr.ror's l-icctrscd tnw (Chrlrfi 9, (iDnrnc ns $ih Scclion 7O(rO of Dilnion ll or rhc Bu\trrr$ Jhd'
<br />l'hrdsn,n\ Codr)orrhrr hc.r shc i\cnnu rh.rciiom ind rlk hrn Inr rhcrllc-lcdcxcDprion Anyri{nrrtrtr'orsc.riotr70ll.5bynny
<br />qrfli.dnr ror. Fnnn rubjNis rhc rpphcml ro rcivilp.trrll! oi rl()I nnrcrtan n\c hlrlrcd dolhr! l55tl(r)
<br />A
<br />-l.i..qnal',lrhun",ncnt.o,rn)c'nnloJ!{\{
<br />htrr!r\r\rhcnv,hconlrnlrnun.Mlldurh.s k Llrhc(turui\kn
<br />i'ncn&d oronircdtur\rlc(Sc.701.l.Rusird*Mdhofcs\i,n\Cod.ThcConrn.toisl,iccnscL,edocsnorlPnltrortrosNroi
<br />rh.Frp.rty wh. huild\ or inDovcs ll{(rnr. rfrl wha dos {'c[ winl hlmsclfor hc^clfor rlhngh hh or hcr owtr cmtloyccs.
<br />nn)vnicJtharsuchnnrhrrnrsarcnnriNcndcd.roltito\ltur{rlc.llhowcr.((h.htril ing.r imtm)vcftnr i\ {n wkhir tr( r!
<br />orcomthri,n- rtf, Osncr BuilLr willlrrc rlf, hudctr of pnniig ihd lf, or shc did tror truilll or i'nprovc rhc pn,I(iy fttr thc PUrtrtol
<br />_1. a. osmr of rh. Flpdry, m.xclusiwly ont tinS wirh licctrEd contn.los ro oBmd rlE l'rchd (sd.7044. Eusms
<br />ad hofEsnfl Codcr Thc Contreror's Liccn* Law d@s tur qrply ro m owner of rmp.rly who huil& or impots lnd@n,
<br />{nd wh6 onrEcls tu such pmitk wirh ! Commclo(s) lic.trsd pusu ro rhc Contradois Ucc$c L{w).
<br />I r r.rc rt, uidc' Sc.rn)
<br />Irarr
<br />wonKFls' coMPn'NslrroN
<br />DECITTBAIIAN
<br />I her.by rrfirn under rEnahy of lErjury orc ollhc follo* in8 d(lmulions:
<br />I hnvc fuxlwill flnnriniCcnificircofC.trscnrloSclfnr{urcri,worLcncoEpcn\rrn,n.a(Pr.vid.dhrbyScctionlT0ooirhc
<br />lrhrCodc. rn'hc pcrrornDmcorrhc qo tur *hichrhc t'.nnir is i\\ucd.
<br />I h!v. .nd will minrain wort 6 compcnBlion insuD*c. a3 rcqlit{ lry S(l ion l70o of UE bbor C.dc. for lh. pdfoll11aN of
<br />thc wqt for wnich rnb n mjt is Ls$cd. M, workm ompcretiotr insuorc @rhr !d poliy numb.r msrrfra fudD
<br />z6\tr- zod
<br />l.cniry rMr in rh. p.rrormRc ofrtc work for which fit Frmil is GsEd, ! shallno' cnlpl,oy rny Fson in lny mnmt
<br />$ ss ro b.sm $tjsr ro rhc &.lcB'@npe tridion ldws o, Cllifomia 0.d .BEc lhll if I slnuld b..om slbi*l lo rth
<br />*olisl coqxnslrion rovision\ o, Sc.rnrn lIlO of Orc tibor Gxl., I stu L ffflhrilh cotr{ y *nt lhos pnlirioni..
<br />WAnMNC: Foilurc ro *cuE so m compeflerion covcraSc is unlawtuL and shlll rubjccr m cnlrlorr lo sininal Fnelris and
<br />civil nncs up ro onc hundr.d tho!,!nd d.lla6 (S100.000). in and ion lo rhc cosl ofcon{Em.lion. damScs !s ptolidcd to.lhc
<br />rh. tihor Codc- inlcrc( and arloma
<br />!EC!t[dIrQIi
<br />I hcrchy dlirmund.r p.olnyorp.rjury rhd I n li.tnst uMcr pmvision ol Chlprcr 9 (conrtuncin8 wirh s.dion T(luJ r ol Divnion 3
<br />of lhc Busiftss nDd loitsion\ Codc. dftl ny liccnse i\ in llll tur.t 8nd ciatr
<br />+qo333C,-F?3
<br />t*I
<br />COIIIAIJEII()NITNDIXCjIIIN(}
<br />I hcrchy.tttmnndcr t'cniltyolFrjuryrhar lhcr is ! connrudion hndin-g as.ncy ror rhc Pcrroiituk_c oi tl'i- qqk tnr shich rhi\ p.nni il
<br />;s\uc,l rs.c lO97 Civ C I
<br />Affllc NLrErta&u&N
<br />I rrn$y,fm undm p.trrny olrcrrury orc oldc hllownrS dLtldrtbnr:
<br />Dcndirio! Pcr.rirs Ash.no\ Norilr.arion Fcdcnl R.guldions (Iirlc.l0. Pd6)
<br />Rquirod lr(cr of Norihcdnr
<br />I ify rh,t rhc Ldfial rc8lhrions rc8uditrB asbcstos rcnFval arc not amlicablc ro rhi( pojNl.
<br />fiar I h0vc rcad rhis apllicolion d slltc rhur th. oh)r infuturion is.olft' I 186 ro mmply *ith rll Ciry and Coonly
<br />rh,vc n*trri,,n.d pmp.n, lnr
<br />L-
<br />io4 dn fi.Ehy autlFria rm*.llrircs ot ::w:
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<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 Pipino
<br />Roof Drain
<br />Tub/Shower Test
<br />Rouqh Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line h., +.a-q
<br />Main Drain/Pool Pipinq (lrtD
<br />Fill Line/Back Flow /'Q>
<br />Pool Heater/Gas Line tD ,11J
<br />Miscellaneous
<br />Water Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Rough Plumbing
<br />Final Gas Test
<br />Meter Release It
<br />FINAL Vluln tur16.to,/
<br />Notes, Remarks, Etc.
<br />I
<br />PLUMBING.INSPECTOR RECORD
<br />Gas Service
<br />Back Flow Device
<br />Lrndd'.4'U'.{
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