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PLUMBING.INSPECTOR RECORD
<br />O1INIiR BI]II,DIR DELCARATX)N
<br />I hc!.hy afltn undcr F-nah, of ,,r!ury rhir I am cxcmpr liom rhc Conrr(kD L{.ns tiw lor lhc folloeing rcNJn ( s'c. ?01 1.5
<br />susnr$ !trl ltolcs\i,)n Codc): Atry Cily or Co!trly which rcqltcs , Fhir t' ..nndcr. (lrcr, improvc. d.nYn or rcp0tr rny
<br />itucrrrc- pritr t, irs i$u.ftc. rho requncslhc +pliclnt lor \u.h pcflnir ro lilc r siAncd (dcmnr rhar h.oi rhc k liccn<l Dusurnr '
<br />ro rhc F,vnions of lhc Conka.t" r Li.cnscd Lw (Ch:lprcr 0. ConnncNins w h sc.rion ?(xlo oI Dirisn,o 3 Dr rh. Bnrms ,nd
<br />PmfesiosCo(lc) orrhrr trorsl[ i!cxcnrfl lhcrclRnnand thc hlsh turhcrllclcdcrcmnlion Anrvi.llrio..fsccriotr703l.5byinv
<br />Jmlica r tur r r.rmn suhr.-irs rhc npplicul lo r civil pculrtornor xrc rhan 6vc hunntcd dolhA (S5ml
<br />-l.rsownc,olrl,crnlddy.ornrycnrPloyccssilh$.scsrsrhcn$kmml.nsin,n.silldoth.wrkrntlihcdfldurcisnotinrc'kltn or ofiardd ior Mk I Ss 7014- Bu\i',cs Md Profcs\nrnt Crd. TIE O)nr.crr'\ l.ic.n{ IIw docs tror lplly io 4 owncr of
<br />ihc pmpcny who hiid\ or inqnDvcsrlHsnr ond rvh. n@s \u.h M hnnsclforhcrslf.rrhroughhisortcro*ncntployces-
<br />lnivid.d rh(r \Elr im|n)vcnEnrs ,m nor i' cDdL{ ur onaNl tur slc Il ho$!vcr. rh( triu i g or in,trn,tnrnr r uld wirhin onc ycrr
<br />of..'mhriotr, rhi Oqncr Buildcr willharc rhr b.nlrn ol proving rhd lf, or {hc did nor huikl or inrlocc rhc lsFny lot lh. rtr/r{ ol
<br />-1.
<br />a\olrrolrhetopcny. dm.r.lutivcly. nkrlin8 wilh li..nd cotrrrctor\ ro connn,cl rhc Pnj.cr lscc 70r'r' Bu\ilc+
<br />$d l\rf$sin Codcr Thc Conreroa! l.ic.n\c l-a* J{rs ior rtlly h rtr owncr.iproFnt sh() hxild\ or nnf'rcvc. rhcrcon.
<br />rnd $ho .onrr&i\ r \uch pFlccrs*nh0Conlr {,(n liccn\.d pohumr brh.Cotrrrrtr \ l-i..tr\c l rs)
<br />-l
<br />d crcmfl un&r Sclion- B. & P.C. lor ili! rclson.
<br />WOqI(FL(' COMPF\ISAAION
<br />DECI.AMIION
<br />I hcrcby affirh !nd.r pcndlry o{ pdjury on. of lh€ following dccleltionsl
<br />-l
<br />h.vc !d will mintdn !Ccdirr.ie of Co.e lo Sclf-l.surc lor wdiss @mpcNr6r s Fovidcd for b, S*rion l?OO ot tlE
<br />Lab6. Codc, for lhc p.rtolrlffie of th. wrt to, qhich rh. ponir n issu.d.
<br />snd will minrainvo.kcd compcnelion iniurarc.. a\ rquaEd by Serion 1700.f llrc L,bor Co.tc. aor llE Pdlotuc of
<br />My trr.k$ o'npcndn,n nhtrr .c crnicr rd Flicy nu'nbcr dc:
<br />rt{,c,ol l^ ,t\s l.\.\r
<br />I ccdily lhd in ihc lcrfomn* of rh. qork for whi.n rhis Frm it hsucd. l shnll nor cmpl,ot afly Pc6o. in a., mmmr
<br />s NrotEom$bhdbt wortcs coqrnsal ion law\ of California snd !8R lhal if I sholld bccod subjccl lo lhe
<br />m cs @nl'cniolior tlrovi3irns of SNlnri l7m of lhc Lahor Codc,I \hall ,onhwnn onrPly *ilt rhd* prcvisions
<br />\VARNIN(; I'riLur. k) $.trrc qor[c^ con,Iltn\rrio1rovrrrE.is unlnwtul. {l{l shall \uhjd on
<br />ciril nn.s u,' lo om hundrcd rhousnd dolla ($lm.Om), in addnion lo thc dlmpcs as povidcd for rh.
<br />":";"
<br />i'LlH'U's" 2u Tq#;''"
<br />I h.rchy.ffiiinu c, rcnollyorpcrjory rhnr I a'n lion*d und$ lovnion otCha/.r I Gunmrcina *irh Sc.rirn 70m) .r Divi\n'n :l
<br />of rhd Ausincssmd Pmlcsions Codc.,nd ryli.cn{ h nr fxllfor.. md cl'lccr.4.\04r1 ,4^
<br />CONSIAUS]ON.LENI)IN GDN.I]I
<br />I hcrcby.fllrnr undcr penily of pcrFry rhd rhcc ii r cotriructhn hndins asmy f{r rh. |..lormtr.c ofrhc *o,k ror ehich lhis Fmn i\
<br />nsucd (Sc. 1097.civ C ).
<br />A.tTUCANI.IIrcL/${IION
<br />Itinhy dlinn uftlcr pctr.lry ofpcrjur, onc ofrtu- tblbsnrg dc.lr.lionr
<br />Dcm'liri.n Pcrmir\ Aqrtios No!ificrlion ljcdcral Rcsuhlion\ (TirlcJ0, PM6)
<br />-Rcq!ncd
<br />I.rrcr.r N.!incttintr
<br />-lqxrfyrhd
<br />lhe lcdcnl E!!hrbB Elddm8 8rh.s
<br />4nnt rnrl t n'w cd hE lr,r,r*atrn ord nsr" rhdr
<br />ros rcm)volsc nol dffltdbl. k, rhis roi{l
<br />mrion t conecr I csre ro on ly wirh aI Cilyrnd Colnry
<br />odinrccsudsrar.Lr$rcl,lin8lobuildineco lurhorir EFcrnrarircs ofrhis Cny Md Cou.tylocni6 ufon E
<br />abovc nf,nrioncd Dnpcny lhr a6\Ierion
<br />/\Dpli.rnl or,\Eenl Silnalue:
<br />ID/SIG.COMMENTSAPPROVALSDATE
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under f loor
<br />Gas-Underfloor
<br />Buildino Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarilier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Piping
<br />Rool Drain
<br />Tub/Shower Test
<br />Rouoh Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Main Drain/Pool Pipinq
<br />Fill Line/Back Flow
<br />Pool HeateriGas Line
<br />Miscellaneous
<br />Gas Service
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />s/tzlu ,I\6LHough Plumbing
<br />Final Gas Test
<br />Meter Release
<br />FINAL q/L,tnfl 5\dt
<br />Notes, Remarks, Etc.
<br />pai.y lr.,l., @e,ri,*,
<br />bnl
<br />l1
<br />Water Service
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