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PLUMBING-INSPECTOR RECOHD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUII-DIiR DI]LCARATION
<br />I herb, nlrth lndcr |cnalry ol pcrjury that I am cxcm[ from rhc Conr0chr l-irctrsc Un lor rnc tullowins rcn$n (5€.7(,]11.5
<br />Btrsincss and Pnfc\rnrn Cod.): Ary Ciry or Counry shich rcqrtc\ a pcrmir t' con{tu.r. rhcr. impn,rc. d.n,lish or rprn any
<br />\rruclur.- nrid lo its tsulncc. rl$ rcgut sthr lPplicrfl nr \u.h Frnrir t, iL r siSNd $nrcnEtrr that hcor rh. is liccNcd pur{r nl
<br />ro lhc pnvisions ol thc Co mctor's Li.cns.d Law (Chrpr.r 9, ConBrncin! *irh Sccrion TlXn ot Divhbn:l ol rhc Buqncss nnd
<br />PmtcNnrnrCodc).rlhll hcor\[c n cxc'nor rhc.cLom mn rhclnr\is ior Ihc rllqed cxcnrntion Any violnrionotSsrion'70.]l5 hy ray
<br />aplli.r r ror aFirnir \ubjc.rerhc alplicrnr io acivilpcnalryoanor mrcrh3n fivc hnodrcd dollnrs l$5{D).
<br />-1.
<br />r\ orrrr ol rhc ,n|tn,-. rtr nry cnl,ll('lccs wirI wrAcs rs rh.n q' b (on]F..n\rrion. q ill Jo th. rok al ltu (nErE i\ nur
<br />iJn.ndr! orollcrcd tr {lc (Scc 7l}4,1. Bu\i'r.s\rnd ltolt\\i{,n\(ixh,'lhcGnnrrcnn \ Li.oi\c l-rtrdoc! not 0!t!yr. inouncr.l
<br />lhr DN,trd, sh) htrikG or iDlnorc{ rhcc'n- ud \ tx' les \u.h sorl him\clfor h.^clfor rhtr,rsh his or hcr o*i c'ntl,)yc.s.
<br />lmlnl(lrhrrtr.h i'npmecftf,r\rr mrn[c ]cl orollcrcd n)r srlc Il holvcvcr, rh. bu iui.g or i'npnnrmnr tvJldvirhnronc )r,tr
<br />ofornplciion. rhc Oqkr auiklcr willhdrr lhc budc. oftrovir! rh.r h. or \hr dkl n, build or nryrort rhc pmFny tur rll puq[r ol
<br />-1,
<br />asowm,.trhc pmpeny, deicturivelyconradins *irn licc.scd conrracro^ ro.onsmd rlr pmier lscc.70,l:l. Busircs
<br />rnd iioltasion Codc: 'rhc Conl@lols Liccosc l,s docs not rpt,ly lo e osncr ot pm!.rly wto huilds or improkr theion,
<br />aM who @nrach lor slch rftjc.ts sirh a Co Bcro(s) Iiccnsd nuGunt ro rhc Conrturols Liens ljs).
<br />-l
<br />omex€mrt lndcr S(lhn-, B AP.C lorrhisrcisn
<br />TOIf,EIS:COMEEMAI()U
<br />DECIASAIION
<br />I h.Fby llIrm uodc, ,.n![y of Fdury onc of rh. lollowing &.Lndons;
<br />L,,ktr (, c- turih. prnnnn$.c ol rhc *ork ,,n rvhi.h ihc ncrnil i\ irR'cd
<br />I h,rc ord will @iolai. wortcR ompc.sarion in$om, as rcqliEd by serio. l70O of rhc t bor Codc, fo, tlF p.rfo'trEm or
<br />0E Mrk for shich rh! p.m,t n ilsuc.L My sodc6' @nqxisarion insum cdic, dd Dolicy mmb.r e:
<br />S-@-r€ Fur-,D
<br />I -7-(- 24F.
<br />-l
<br />ccrlify thal in rh. lcr,ormncc oflhc *o* for vhich lhh Frmil is issucd.l shtrll not cmlloy lny pcMtr ii liy miEr
<br />s * ro h<|ft subjd ro rhc qdt.s con ..$ion lrws of C.lifoni., dd lse Oir if I st uld tr.o@ $bl.r ro rlE
<br />wo*ctr' codpcisarion povishnr of Seli.n l7m of lh. hbor Codc. I dElL ronhsnh @nply rnh rhos lFvisiori..
<br />WARNING: F.iturc
<br />'o
<br />surc srtcre' compcnsdion 6v.mgc ir unh*ful. 8ft1 sh{ll suhid a. mplors ro aimiMl Fmhi6 ond
<br />civil fims up lo orc nundEn lhousa.d dolh6 (Sl0O.00o). in rddnion l. rh. cosl of.oq,cnstion. ddmgcs as pruvijcd for th.
<br />Sstion 3076 of thc hbor Codc. intcrc( rnd anormy s fes
<br />,",". *-l- la ,r
<br />DIII,IAAI]I)N
<br />I hcrcbylffiii u*lcr prhlry of IL rjur! rhd I m lico \!l uidcr pmvi\i,D ol Chrprcr 9 lronnJfn.nr! wiih SLtrn,n 7U)O) .l Dirisior I
<br />or rtu llu\inuss rod hnc\si{rxCod.. url arvli(cnr i\ in,nll i,rcu rlcr,..r
<br />cI(1872-
<br />o"", ?'t-[8 c-,
<br />IaNSIBU(:UANIIIDINC.A(iDNCI
<br />I hcrc6ylrlnnrundcr pcnrlty.lFrjlryrh rhcrc h!con{ru.!ion hndin8 oserc} iqrhc pcrli,rnBncc orrhcwork tn !hi.h lhjs Fnnir i\
<br />i$ucn 1s.c :1097, Cir. C.)
<br />a.&uraNfD[cIJxL]
<br />I lel,y nmundur ncnllly olpcrjrr! onc ofrhc ldluwins dc.lorlliotrs,
<br />Dcmlilnrn Pcirnils-Asl,cstos Notilicorion Fcdcrul RcEuhri.ns (Tirlctl0. Pin6)
<br />-ltcq!ircd
<br />lxrrcroi NotiaElrion
<br />I ccniryrhrrrhclcdcralrcsuhri,,n\ rc!idn,e r\$c(osrcnxnrl c noknplicrhlc ro rhi\ proj.rr
<br />EI..nilirhd I hrlcrc rhn,mli.dnrn a'rl (dc rlrrrhcrh,vr i'rnnndirnr i\.otucr IrEi.rb.o lny s irh all cir, aM Lhurty
<br />urdinri(\rndStrrctissrliii!bbu,ld'ng.on{dcrnnr dh...byadhori/c.cDrc\cnrarilc\{nrhirCiryMdCDUnrytuctrr$u$ lh(
<br />rhi)lc nNnliorcd pra|Eny li)r in\pcclion pulpo\cs
<br />Applic! orAgcntSiAnrlu hi\\;
<br />Q-t-L- t-0
<br />UNDER GBOUND
<br />Waste & Vent
<br />Gas-Underfloor
<br />Buildi ng Sewer
<br />Area,/Storm Drain
<br />lnterceptor/ Clarilier
<br />TOP OUT
<br />Waste & Vent
<br />Water Piping
<br />Gas Piping
<br />Roof Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />P{raplDrain Line
<br />Main DrainiPool Piping
<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 />Final Gas Test
<br />Meter Release tt
<br />FINAL llglty ,u41@)
<br />Notes , Remarks, Etc.I
<br />WaterUnder f loor
<br />POOL/SPA
<br />?Wt'z*-
<br />t Jq s JJrc-
<br />Prmlle mne (prinl):
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