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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE COMMENTS OIVNER DUIt,DER DELCA RA'I'ION
<br />I hcrchy rfrl n undcr penalr, oitcrjury rhat InDcx.m lntrnrhcO rr.ros'Lianrc I!* In ihc f{,ln,wn'! rcasotr iscc 70:ll5
<br />Busi[c\s ind I'>rofcrsi,,n Code) Any Ciry or Counr, uhi.h rL\]ui,t\ r tf,nnir ro otr{fl.t. rlrcr. i'npo!c. dcmlish or rcnrtr .'ny
<br />nrmrur.. pridro ils issunn c. $ {qunc\rhc ryplicrnr forsuchpcnnii h rlk! li8ncd *ir.a*fr rhd hcor \hc t licciwl ttrrlrjir
<br />b rlE pn,!isn,n\ ollhc Conlrrcror's Licctrscd ljw (ChtlPi.r l). Co m.nci!1! sirh S..riotr 7(Xx) of Divnion :] of rltr Btrsirc\s lnd
<br />Prolis\i{rrs Codc) or rhrr hc .r lhc is ercmrr rhcrcirom md rhc brsk f.r rhc rlic8cdcxcnDrion An! violarn'notSdion 70.115 hy rny
<br />npplicaN tur Nnnn sur,.,c.B rhc rmli.nnr ro acililpcnrllyofnol morclhatr fivc hundrcd dolhr(S5m)
<br />I.asowtrc'olrhermNny.ornrtcnrttoy.crwirh*rgc\rsrhcnR,bconpcnsdnrn.willdotltr$orkiMdrslnrcrur.i\ior
<br />i crdd orotlcrcd f(tr slc (Scc 7(14,,1. Busir.ssrtrd PdassiotrsCdl. ThcCotrr..tor's Li.cnsc Lrw doc\ not dptly lo atr o*rcr of
<br />rhcptulcny aho huiLs.r iDtrovcs rhcto\'n. did who (rssuch(orkhnnsclrorhcr\clf.rrh&ughhis.rhcrowncnrtn,yccs.
<br />p(,!id.d rld ch impn,vcnrNs tm ior inrc lcd or ollircd l'or srL lll h{,$$ ci tnc boildin! or nnpnivcmf is sokl Birhin orc )! r
<br />oiconlhrinr lhc Osi.r Bdildcr willharc thc hurdcn ol nrous rlrr hc or shc tlid nor huild or i'ntmlr rhc phpcny lor rhc purrN ol
<br />-1.osowncroflhcpmp.ny,.m.xcltrsivcly.o
<br />rtclins *irh liens.n conrracrosro $nlirucl ihe pmj.rl (Sd 7044. Bliincs
<br />md P,rttsi.n Codcr 'rhc ConrEcrols Li.cnse lnw d@s not amly ro an ownc. of propcny vho builds or imprcrcs thcrco..
<br />and wto ontracls lo. such poi.cls wirh . Co 6cror(9 liccnFd pucusnt ro rfic Conmcrort Licclsc l-w).
<br />I {ncxcnrpr lndcr S(t
<br />uaf,KDAtlloMt[lsArlo!
<br />DECIdBA.IION
<br />I hcrcby niliirn undcr pcnally or pcriury.nc ofrhc tollowins d(ldarions:
<br />I n,vc onl qill msintain a Ccnificrrc ofConscnr to Sclf.lnsuE ror vorkctr onpcnerion, ns providcd for 6t Sccrion lT0ooirhc
<br />Lllir Codc, lbr lhc pcrformomc oflhc wolt lor which thc p.nnir i\ issxcd
<br />Vh c r n,r , ill rndinl,m rorkcF comncnsar nn rnsurlKc. as BquiEd by scctio. 3?0o or lhc ljbor cbdc. lbr thc pnlbrmncc of
<br />thc {or* for shich lhir lemi is issct My *orkc6 compcnelion insurine c.Eicr md policy numh.r scDl9 CrUPGT>
<br />/", ) ,un)
<br />I.cnilirhd n, rhcp.rronun..ofrhc wur( fq whichlhh pcnnil is
<br />^\ucd-
<br />I \hrll nor cmphrrny
<br />s N lo bccom subiel b lnc *oltsc coolp.ns ion l.wsofcolifor.i0, md !8rcrhol ifI should hccom sub.jcd lothc
<br />workem comtcnsalion prcvisionsofScclion 3?00 ofthc t$or Codc.I sh.ll. lonhwilh omply wilh thosc pmviions..
<br />WARNINC: F,ilurc to surc worke 'comrcnsa'ion ovcmBc is unlartul. ond shlll slhjel an cmplorcr r. (imin0l pc@hics,nd
<br />.ivil fincr ut lo onc hlndrd rhou\add dollus (5100,000). in Bddiriotr ro rfic cdsl ol coFpcn\ario.. .la@gd as rovidcd ror rhc
<br />inrc'c{ Md orrcr's lrs
<br />,r.r-]
<br />!11!!2llid1la!
<br />in und$ I.nolrrotI)€rjlry lhlt I am liearn undcr prolisionotChaptc.9 (ommncins,ilh Sction 7(](xl) ofDivhion 3
<br />of the Busircssand Pofcssions Codc, dld mylhcn€ t in fxlllde md cfi*r.
<br />11_
<br />CONiIts!j:D0NIENDII$:IIiIN!I
<br />issrcd(Scc .li)97-Civ C )
<br />APfLICANIDECI.ABAIION
<br />I h.dry affm !.dcr lenalty of lerjury ore of rh. folk qins d(hrutions:
<br />DcnDlition Pcrnits-Ast sros Notific*ion FcdcBl Rcguhrions (Tirls 40. Pdn6i
<br />Rcquir.d lr(rr dlN.rilicdioi
<br />-l
<br />ccnilyrh lhc fcdcml rcgulaliotrs Egarnin8 osbcstos rclmvalarc noramlic.blclo lhis rmjccl
<br />l.cdi,tr lhrvc Bd rhi\appliclrion rd {rrcrhd rncahovc inforn bn nconc.r I tBrd ro n'nrply wir h all Cir! rtrd C.unry
<br />.rdinrkesMdSr,r.ttr*\rhrinEk,building.ondturion,lndhcrcnyauhoritrcprc\cihriv.solrhisCiry,ndCounrybcmcru!.nrh.
<br />lhvc mnttuncd lropcny frtr in spc.l ion puryoses
<br />Applic.nl or AEetri SiaElrre *,"-zf nf rc/
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Building Sewer
<br />Area/Storm Drain
<br />lnterceptor/ Clarif ier
<br />TOP OUT
<br />Waste & Vent r /- l, z>^[^-Waler Piping f/r rqlty'''q-zL
<br />Gas Piping
<br />Tub/Shower Test
<br />Rou gh Water Heater
<br />POOL/SPA
<br />P-trap/Drain Line
<br />Main Drain/Pool Pipino
<br />Fill Line/Back Flow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Lawn Sprinkler
<br />Sanitary Sewer/Cap
<br />Back Flow Device
<br />Rough Plumbing
<br />Final Gas Test
<br />Meter Release
<br />FINAL J/z,t/n 4,#ql
<br />Notes, Remarks, Etc.,lo/"rlk ilbtu / aoa I'*._ .-,M-)
<br />I
<br />ID/SIG.
<br />L,r-.dcr'. AdCrc$:
<br />-
<br />Roof Drain
<br />Gas Service
<br />Water Service
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