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PLUMBING-INSPECTOR HECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OITNI'R BI]ILDEI' DEI-CARATION
<br />I hcrcby tr!finn undd rcnilry .ri t8iury lhnl I rm crcnur lrom lhc ConrrJcro^ t-i.cn\c Lnw n, rh. nr[,]ins rcl$n (S.c?011.5
<br />Dn\ircr\ rnd Pnnt$i,,n Cqt) Any Ciry or G,Lnry which mqrnc\ n rnnn n, .otr{rud. .lrcr- nnnr.\c. lcnnri\h '{ rcnrn ,,ny
<br />(tudur.. priortu irs i\\uan.c. rl{ icqurc\ rhc {rDli.nnr r(tr !u.h Fann b lilc r \ilncd {lrctrrnr rhir hcor \hc is li.cn{rl Pusurtrr
<br />kr lhc |novisios ol rhc Conrr!.ktr \ l-iccnscd liw ((hrpi.r L C.n ncncnrg wirh sc.rion ?(xD of Division 3 of rnc Btrsid.ss and
<br />.ttli.n ntr rlf,nlnr subjc.Grhc opplimnr r' ncivilpcnslryoin.r nFrcihrn i_Lvc hu ndRl doUr\ ($5(D)
<br />l.$owtrcrollhcpmFny,ortrryemtn,yccswilhwrscsu\rhcir$lccompcn\aii{rr.*illdorh.s{ andrlE(R1ucisRn
<br />inrmlsl oroitrcdl'ors0lc(sa7Or-1.Bu\in.\\mdPmlc\\nrn\Codc:lhcconhaclolsLi.cnschwdoesnorflmlyro!noen.ror
<br />rhcnnr|ity sho huius or nnnrx$ rh.N)n, !'xl who dRs \u.h $* hinrcllor hcrsdllor rhsuEh his or hct own cnDbyccs.
<br />Drcvnhd rhdr \u.[ nnlmrenr.r\ @ mr idcndcd or ofiscd t'or \ah ll: ho*cr.i rhc Soildin8 or irpnntmnr is $H wirhir onc ,s
<br />or.ontphri,n. rh. o*ncr Buiu$ sill ltr\c r bunL. of pr.vin8 rhd lE or shc did d h'ild or i,.4r,t rhc rr,Fit tor rhc Nqss of
<br />l. ar 6wn.r oa ilB l'nth,, an.x.lusiv.ly ronlr.ctif,B wnh lanrcd conlrKxE lo oonod rlE !oj.!t (Se 7G14, Buiiftrs
<br />and Eoftasion Codc: Thc ConrMror\ Lk.nrc tiw dfts nor qDly r. d owncr of lrop.ny who builds or ihpovcr rhe.co..
<br />rnd who .o 6cr fm sch pmj$rs wirh ! Connftlo(9 liccnEn pu*u'n ro thc Coniracror's LBrs tjw).
<br />I lmcrcmD' undcr SNriotr . B & PC for lhn rN\.n
<br />l)ll.: O*ner:
<br />loaf,E&:t!]!4rENsAtr0N
<br />DEIIdSAII(A
<br />I lErcby lrtrn undcr Pcnlh, of rdjuy om of ln. followinB delaBri6Bi
<br />-l
<br />hrvc uftl sill trEinrli! ! (cnificlrc of G,n{ r ro sclt hsurc rff $ukci. con\tuns i(,n,$ F,vidcdlnrhyScrrio.l7U)orIhc
<br />L,h, (r)dc. rr rhc lttrllnnnrNc olthc so rhr lhicn lhc rcmil is nsucd
<br />I hlvc and eall @inrain wortc* corycnsarion insummc. os Equircd l,y Ssrnrn 1700 of rhe L.h., Cdl.. for lllc rsftrtrre of
<br />h rhis pcmil n ns&d My *ortcN compcnsalion insuroN @icr 6ild rblky numh.r m:
<br />4OCC,-11 7'lL1 \tr
<br />-l
<br />ccnit, thar in lhc Frfor.run c ofrhc work lu *hkh lhb Fnrn is issucd, I shall nol employlny p€en in any manroi
<br />s rsro tE .m.uhiyr ro lh. worlEl o,rqFnr.rion laws ofcaliforni!. dd agm rh{ ilI srbuld h..om $tiNl lo rhe
<br />workdc ompcn$tion lmlisionsofScrton 1700 ofrnc tjtnr Cidc.l rhrll. fonhqirh comply wilhrhos pmvlsio.s,.
<br />WARNINGT F"ilurc lo scun polkcs comp.nsalion covcEsc is lnlaefll. dd rh8ll strbhcl m.mplotlr lo aiminal I'cMlrk. dd
<br />.ivil fi.cs up ro om hundrcd rnousand doll{s (SI00.()O0). in rddirioi ro rhc corr of coiiFnsiliof,. dam8cs os providcd for lhc
<br />Scrion 1076 of ttrc tibor Codc. inteten ud lrromy s
<br />,",", -l-11.\t
<br />IXCIAMIITN
<br />I hcahyain unncr pcmlry ol Frjury rhd I li.ci*l undrr F,ri\i(,n ofchrrlcr 9(.omrmmin! vith Sari,n ?off)) ofDivision:l
<br />of rhc Busin.* rnd Piofcsri{,ns (ndc- md myliccns n h tull lorcc unl crltcr
<br />L3 t-\0-L\ta\
<br />CONSTRTJCTION I FNNINC AGENCY
<br />I hcrcby affirm undcr IEMlry of p.rjury rhd rhm k ! mftrtu lion hndinS agcncy for lic psfotmre of lhc work fo. which lhG lcmil i(
<br />issucd (se.109?, civ. c.).
<br />AEELICANI.DES.AAAIIAN
<br />, h.n:6y altim undcr rcoalr y ol pcrjury oft ol rhc rollowins d6b,ario.\:
<br />Dcrmliion PcrmnsArbe(os Notificariotr Fcdc,al Rc8ul ions (rirt,l0. Pan6)
<br />-RcquiEd
<br />Lcrtcr of Notifi curion
<br />-l
<br />.cnify rhlr 0E fcrkdl Egpb oos E8{iling a.b.slos rcmvr! m ml .p,licabk ro lhn poj6l
<br />I ccnitirhar I hnvc rcad rhis otpltarion and sr.rc thot tnc lbr intormrioo k.ond. I r8e loenply pilh ![ Cnylnd Colnr,
<br />ordintrtrfti rd s{arc tr*s Elalina ldiis co.ntucrio nd tueby autb u c Eprcenrariws or lhk Cily and Counry lo c.l6 uFn tlt
<br />ibdv. mnrioncd toFdy ror ins 1\\ lY
<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 Pipino
<br />Gas Piping
<br />Roof Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Main 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 L
<br />Rough Plumbing 7"17-tY h "V/jlil,
<br />Final Gas Test V
<br />Meter Release
<br />FINAL ,.r1_tq ttlauzr<6")
<br />INotes, Remarks, Etc.l
<br />$/-\-f
<br />il,,t2""k.,[^
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