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APPROVALS DATE ID/SIG,COMMENTS OWNER BT]ILDEII DELEARATX)N <br />I hcrcby nlrfln und$ |)(..lly ('r pcrjury rhdr I n cxcmnr ri.nr rhc GniB.t*s- Liccnxc l.!w ir rhc nrl[rwila rca$n (s'\701l s <br />Bunncss rnd P()lcssi{nr Onlt) Atry Cily or Counly which rc+irus I lfanir h con{ni.r. rlrcr. improvc. dcn$l'\h or rcnrt anv <br />{ocrurc. Drior b ir\ h\rdn.c. uho rcqutc\ rtu atpli.Mr fff $.h Firtril l(, lilc r siBftd i dcnEnr lhd ltor\ht is licctr{d Pu uxnl <br />n, rh tmlntnt oi rhc conrrlcloi\ Li..n\cd uw (chrlrs 9, c{nn tr0S $nh seclion 7(xn or Dlvision I of rlr Rurnnx( rnd <br />Pnni\\iotrs Conc)orrhnr hcor\h k.rc,nfl lhcctonond rhc hr\h for rhc rllcscJ crcdprion AnyvioldionolSc.riotrT0Sl.5bvonv <br />rDrlicatrr tur ! r'.!mir \uhjc.rslh. {prlicanrl,r rciviltcnalryol nor.rorclhln llvc hxndrcd dollars(i5(x)) <br />I. dr o*trcr ol rhe prlfny. or nry cmployc$ snh was.r !s $.n $h .onrlcnvr iih Nill do rhc $ork a.d rlE i Mrm is nor <br />i .nd!n or oi.Ed f.i slc (5(.?1}{1. Burin.\! rtrd Pt,rcrs nl Cdc: -rhc Conra.ror's Licctr{ l iw dtr\ i.r ardv lo o$ncrot <br />rhcpn,Fny Nho builds or n4rcvcs rtuNn. a, wh. do\ $.h *o* hinrclf or hcrclf or rhooFh his o. hct o*n c'npbvc.\. <br />prorided rlur fth nn!()vcNnrs rE Bn inhndcd M offcrcd f s0lc. ll, ho dtr. rh. b{iklitrg or i'rymlcrm is sU wirhin otu ttd <br />ol.oDd.lion. rlt Owncr Buikld Billh.!c rhc bunlcnorF,!i'r! rl hc or slrc dii B, hdiu or i Imlc rhc PR,lcdv ror thc lrurlnEol' <br />-l- <br />rs ow,f,r .r rhc Folxny. im c\chsiecly .ontr.rnrg q{h li.cn{d cotk3cr.s r. conslrucr rh. Ir(,j.tr ( scc 70's. Btrsift\ <br />rid PnrL\sir (.odc:'lhc Conrr.tn s Licc.sc Law d..\ nor aPPry ro.notrncr ofPm!.dy qho builds or i'nBrvcs <br />'hcrcon.rnd who cont(chnrlu.hlnojccls*ilhrconrtu.rod\) ri.cnscdlru6udr b rhc cbntackn s Lic..s.l-Dw). <br />-l <br />!h .rcm un lcr 56 <br />O*ner: <br />YOBIEIS:.COTdPJIIAIISN <br />DECI.ASAIION <br />I hdcby rffim !.dc. pcnaht of pciury o.c of rlt follo{ing deltltions <br />I hnve ud will minrlin ! CcnarMr. ol Cons lo Sclt lnsurc rot w.rkcn conq*nsrion. ,s polidcd for b, Serion lr0o of lnc <br />lihor CDdc. nr !h. lcrformncc of rh. wod( lor which lhc pc.mir is ilslld <br />-l havc lnd wiu ninhin workcs compe nssrn,i nrsuin.c. rs rcquied hy Sftr ion l?00 of rhc |iht C.dc. lor th€ |'erfotl1ec of <br />rtc uork ror Bhich lhisFrmn k hsEd Mywo.knc ompcnBlion inslBrc ortr &d polty nuotx. e: <br />Policy Nuobcr:-Exltcs: <br />l .rdiS lhal in rlE ,,cr{or@ne ol lhc woIk tu shich rhn P.rn is tsucrl, I sMll Nr cmlloy !try I'cNn in {nv m ncr <br />$ $ro tc&ft ruhld ro lhc mltcr'anF.glion ln*{ of Cllifornh. dd sgm ihar if I sbould beoft $5rel lo th€ <br />wo*sl conpcoqrion DmvGions ofSeclioo 1700orlhe Lthrr Codc, t shall lonh*irhomply wilh rh.r pmvisions.. <br />WAf,ltlNC: FliluE lo 3 e wokc6 con{ENlion covcEge k ulastuL &d shall subit! 4.mplor.r lo dimin l Fdlli* ed <br />civil frci ul to om hundrcd lhouend dollG (llm.ooo) io addhio. io rc cosl of @nvEasdion. dsBgcs <br />'3 Pova'd for rh€ <br />Srrin J076 of thc Llbor Codc, ur.d .d omy < ftrs <br />ucENlrD-colirxacrlle <br />TECT,IXAIIAN <br />I lErcbylliirmondcr FnrtryofFrjury rhlr I !m lirtndl uid.r lmvision olCnllprcr 9 (onnmncia8 wi'h S(ri,n ?000) orl)ilision l <br />or rhc Busflc\s0nd Pd'cs\n,ns codc. d ry liccnsc n in lull n)mandcfLcr <br />-k.nic Nnmh.r: <br />--- <br />Co Nlor:- <br />coNgrBugrxlxrElDlNcllilllr <br />I hcEbyaffi, ufr,$ Fn.lry of llcrrrirr rh th@ i a onirudion hndins dscmy lor lhc l,cnnrmn { oi rh. work rhr qhich <br />'ht lxrhir is <br />issucd (SE.1097, Civ, C,. <br />Lrndd r:{rm: <br />- <br />-l <br />ccnirythdr rhc lcdc(l rcaullrionl Egddin8 $b.nos tctrxr!{l{c nor rPllic.nb lo rhk PmF.r <br />l.drifyrh0r I havcrcadrhisntllic,tionnn\hrcrhal rh.!h,v. inLrnnlion i\.otrer I aEe lo comPlv {irh rll Cirv lnd Counrv <br />oniindm.s;nd Shlc Llws abriiS t, buildin8 con(rucriofl. a'n h.tby authorizc tqrrcsnhrivcs oflhn Cilvatul Counrv ro cntcr upon rhc <br />atDvc eoin,tud rmpcnytu insp.lrkn purFscs. <br />Apnllont o. Agenl SigErure:- <br />I'emil.e romelprint) <br />UNDER GROUND <br />Waste & Vent 4 I I Lg1 lzv) <br />Water-Under floor I I <br />Gas-Underfloor <br />Buildinq Sewer <br />Area./Storm Drain <br />lnterceptor/ Clarif ier <br />TOP OUT <br />Water Pipinq <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rouqh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />lvain Drain/Pool Pipinq <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 />I <br />Rough Plumbing {z>) <br />Final Gas Test U v <br />Meter Release <br />FINAL f.( \4t) <br />\,gNotes, Remarks, Etc.l(U <br />PLUMBING.INSPECTOR RECORD <br />A.IPLIIAILDIIELIMIION <br />l,srbylnimlndcr penrlry offcrjur, ore ofrhe folhwnrg d..lMlions: <br />DrnDhion Pc nilr Asttnos Nolit'E0lion Fcdcnl Rcsxhrn,ns (Tnh40. Pln6) <br />-R.qunc{ <br />l.rrs orNo lf, sliotr <br />Waste & Vent <br />1 lltQ(