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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE owNER lttIr_DrR D1]_CARA',UON
<br />, hcrchr_ illtn u .r ltrmlry ol FrjLny thrr I cr.mfr t n nE Conti.l,r Li.ct\c I rs i,t rh. nnk'*inI rc vD (Stc 7011 5
<br />!fl.rurc. |tnrr) ir\ n\uin.c. dl\orcqunc\ rhc.pfli.d,rr nn \u.h l*nrirh lllc i \iAocd ndcnrtrr rh lt or \hl i\ li.cn\cd pur\lrnr
<br />t, rhc pmvi\i,nr\ of rhc ci'nlrrcrr'\ l,icctr\cd l:r* (ChnIrcr 9. (innnr.Ni,'s s h sr.ri(r 7(xx) of Di\i\nn I of rhc 8u\irrcs r8l
<br />rppli.trd lnrnttrnni $hjLtr\rhc l|1plr!trrb d.rvrlpctulrtoi nor uc rhni rlc hutrdr.ddoll!^ 1S5U))
<br />-1.
<br />ar owncr ot lhc lorcny. or o, cnploFca qirh wagcr as rhen sb con{xNrtiotr, *ill do llE wdt ud lhc sltucl@ is mt
<br />i.rdrd or orcEd for sL (Se.70,t4. Busims rnd PrDf.ssio.s Codcr Thc ConrBdols Liens Llu docs oor apply 16 s owE. ot
<br />rhc r,Dpcny sho hild\ or iarhhr [t@n, o'd who d.Es {cn @lt fiinrclf o heMltq rhergh hG or h.r own cm,'loycos.
<br />pmvidcd lhlt such irymtmnls @ m! htcndcn orofcnn fo! slo. lf. honwi rhc t{ilditrE or tnrmEftnr is $ld si(nin dc rttr
<br />of.otq,lcrhn, th. olrM auiicr will haw llE t{d.n of Fovin8 rnd ,r or sh. dil mr tni! or ilrrcE r]lc rrorEry ro. dE p6lbs or
<br />-!.
<br />0s owmr of rhc
<br />'mFny.
<br />an crlusivcly contncring wirh liccned co,rEcron lo snntud rL tftirl (S$, 704.4, aLiG$
<br />,nd holssb, Codc: -rhc Co.tncror'. Liccn* L{s d@3 nor.ptlr ro d ownq ofpmp.ny wlb brilds or nnprcvcs lherdn.
<br />strd who c.ntmB for such prcjels with a ContEcio(s) lk.nsd puls to rhc Contnclofi Liccnr. lrw).
<br />-l
<br />amcrcnpt undcr Scdion-B. & P.C. for lhis Mson
<br />truaKE8s:Cr.lllrErsarroN
<br />DECI.AX{IIqN
<br />, hcrc5y 0lfirm u.dcr p.nllly.f pcrjury om of thc followire dehrutions:
<br />-l
<br />hrv. nM will nri rir rCc il_{.tcolconsc r{, Sclllnrurc,nr workcn conrlrt.\lli{r. r\ pnrvid.d nn hySc.riotr]Tmofl[c
<br />bh.r Culc. fir rhc p.rlonihcc of rhc *ork ln whi.h rhc pcnnir a isucd
<br />-l
<br />hrvc lnd will nln air wortcs comDcnsation insrroncc, trs rcqlncd hy Scclion l?ix) df rhc lih.r C'odc. fot Ut lEdnrmne of
<br />lh€ *ort ror wtich lhis tcmil is nnrn. My sortm con{Ensarion insliane cori.r oJxi Fli., nlnh.r ml
<br />-l
<br />Nnifyrhar in thc rErfortudc dfrh. u6,k ror *hih rhh p.rmir i\ is$.d, I shnll mL.nDloytrf,y lcr$fl in !try manrcr
<br />so trs ro h.cDm \ubj.cr ro rh. wrkcc orr.nsarion laws of calirorni!, ond .BE thol if I shotld bccoe subidr ro rhc
<br />wo*cs.omFnsulionrrvhionsofScclion3?0OoflhctjtrCodc.lshlll.fonn*ilhc-'nplr*ithlhospmvisions..
<br />WARNINGj Failurc ro scrc soturc' ..nDcnsarion covemBc n u.hwtul ll subjd un cmployci L dioiml ,*Mhics ond
<br />ofconncnsrion, ddnEg.s ds phvidcd for rrE.ivil i.cq ut rt! onc hundftt rhouend dollrs ($ltu.fixr). in rddirnrn lo rtrc
<br />,,,,. -7 /t'
<br />I hcrby oflirn u.dcr pcnrlly ol pcrjtry rhlr I ao laNnsl n pmvirion olChrrb 9(.omn.in8 vnh Setiotr ?000) olDirision l
<br />of ttE Busircss and Pmrcsiotrs Code. un my licstr€ is in tull forc $d ellar
<br />q/tg
<br />I hcEhy amrm u cr pcnahy of pcdury rhar rh.rc h a
<br />h.u.d (sd 3097. civ. c ).
<br />bn lcdi.g ascfty for iE p.rfomN of rtu vorl tur *hth lhh |rmi is
<br />ATIUCAIiLI]ECLAf,{IION
<br />I h.i'bt tnrutucr pcnolryofpcrjry onc oflhc rbllowin8 delnarion!
<br />Dctu,lirion Pcrmirs A\h(n.\ Norifi.{n,n Fc&rrl Rdgtrhrn,ns (Tnb{0. P.n6)
<br />Rcqrncd Lcrr.r.f N.iili.diotr
<br />-l
<br />c.nily lhur th. fedcrll rcsohrion\ E!0rdina a\hcstx rcmovll @ nor apdic,hlc ro thh pmj.rr
<br />I c.dilyrhd I hdc icad rhi\ otplic.rion ad slatc Ih,r rhc aiFw inlorrotioa i\ corar. I lsre ro conqiy *irh !U Cilyand Counry
<br />ordnBkc( ,trti srirc bwsEhrmS ro huildinS cnn{rud .rxl h.6hy nurrbrizc r.Ires arncs or this Ciry od Cour, ro cnlo Won th.
<br />as{'!c nrcnrioncd lnrFny li,r in\pc.rion
<br />Applicant or Aaml Siatulue:
<br />Pem le,rhe(prld):
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<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 />Rouqh Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />trilain Drain/Pool Pipinq
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Gas Service
<br />Water Service
<br />Lawn Sprinkler Z)
<br />Sanitary Sewer/Cap 9.lL'tE 4...,^a l6s----/
<br />Back Flow Device
<br />Rough Plumbinq
<br />Final Gas Test
<br />Meter Release
<br />FINAL r_LL.t7 47 lz'7\VNotes, Remarks, Etc
<br />ID/SIG.COMMENTS
<br />PolicyNuibcr: Ertirc.
<br />bndcarNsR'-
<br />t ndci\ Addr.c.:
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<br />,/,o/,A
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