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PLUMBING.INSPECTOR RECORD <br />APPBOVALS DATE ID/S!G.COMMENTS olvNER BUII-DI.]R I)I'L('ARA'TIoN <br />l]usinc\s atxl l,()li's\hn Codc): Any City (,r County u'hich rcquirc\ a lr-rmil lo conslnrcl. ilhcr. iilrprc\'c. dcnnlirh or rcprir arv <br />rpplicrnllbrrpcrnril\uhjcrl\lhc applicailtk)aci!ilpcrilllyof[(,lnx)rcthinl'irchundrcddollrrs(55(X)). <br />_1. as owncr of I hc pr 'lrf,y. r)r rny crnpl()vccs wil h s ngc\ r\ lhcir \olc cotrrpen\rl hn. will do lhc $1)rk nnd lhc stnrturc is tr(,t <br />thcpr)J--f,y whohuiklsoritrrprolcsllErqnl.nn(lshodocssuchsorkhinrsclf()rhcrsclt'orlh()u8hhisorhcrowncntpkrvces. <br />providrll thal \uch itrrpro\cnEnts ir fi iric[lcd orolTcr*l lrrr salc. ll. ho$crcr. llt huildinS or inrpro\cmil is wld *ithin onc \trr <br />srlc l. <br />x[(l uho conlrilctsli,r\uchfr()jcclswilhxC(nilrrcktr(s)liccnscrllursurnlkrlhc(bntrilclor'sl,iccnscl.aw). <br />lamcxcmDIundcrsccli(,n-.B.&P.C,forlhisrcason' <br />()snrr <br />WORKERS' COMPENSATION <br />DECIdEAIIQN <br />I hcreby a[f]m undcr fEnally oflErjury onc ofthc following delatalionsl <br />_lhaveandwill nuintain{CcnificfllcofC(nrsnlloSclf-lnsuref(rrworkcrs'compcilsation.as;rotidcdforhySeli([.17{[)ollhc <br />Iitx)r Codc. Ior thc pcrli)riltncc ofthc work for which lhc Jrcrmit i\ issucd. <br />thc rvork lhr which thi\ pcrtrrit is i\suc(|. My w(trkcrs' cotrlpcnsrlk)tr itrsrnncc c{[icr tn(l F]licy nunthcr nrc: <br />Polic!, Numbcr: Expircs: <br />_l ccrrify that in the ff,rformme of lhc work for whkh this permit is issucd. I shall nol cmploy any Frcmn in any manner <br />s as to bcmm subjert to lhc workers'com[rcnsalion laws ofCalifomia. and Egrcc th.t ifl slDuld hc{om suhjct to thc <br />workers'compensalionprovisionsofScction3T0OofthcLaborCodc.lshall.fonhwilhomplywilhlhospmvisions.. <br />IVARNIN(I: l;ailurc to rcurc $orkcrs'conrpcn$tion covcrrgc is unhwtitl. and shrll suhjcct str cnrphyer t) rintintl lEnxlli'\ a0(l <br />civil llncs up to one hundrcd thousand rlollars ($l(X).(XX)). in nd(lilioil lo thc cosl ofcornl)cnsalion. darnges as provklc(l lirr lhc <br />Scction .1076 of thc tjtxrr (irdc. irilcrcsl rn(l rnorrcy's fccs- <br />Applicant: <br />LICEII,IEJLCANTaAIrcE <br />DECLARATION <br />I herchy rlllnn un(ler pcnalty of pcrjury thnt I anr liccn*tl untlcr pro!ision of Chrplcr 9 (commncinE wilh Scclion 7(XX)) ol l)ivi\i(,n :l <br />of thc Busincss aild ltofcrsions Codc. arxl my liccn(c is in lill lirrcc ard c{ltcl. <br />l-iccnsc Nxnlhcr: <br />( r)illrn(lr)r <br />CONS'I'RUC'I'ION LIJNDIN(; ACENCY <br />I hcrcby ilfllrill undcr Fnrhy of Frjury thrt thcrc is a con\t nrct ion lcnding r8cocy lirr I hc pcrfornutrcc of lhc pork lirr shich this Frmil i\ <br />issucrl (Scc. -1097. Civ. C.). <br />lrn(lcr's Nrtrrc: <br />kndcr's Addrcss: <br />APPLICANT DECLARATION <br />I hcr$,y aflim undcr pcnalty of pcrjury onc of lhc following dcclarations: <br />Dcfi)lition Pcrmit\-Asbcsl(,s Nolification Fedcral RcSulflliflls (l illc 40. I'ilrt6) <br />-Rcquircd <br />[,cllcr of Nolificaliul <br />-l <br />cmify that thc fcdcrul regulalions rcgarding Bsbeslos removal arc nol applicubh b this proje.l. <br />ilhovc ilNnlionc{l pr()l)crly tor inspccli()n purlx)scs <br />Applicsnl or Agenl I )illc <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />I nterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rouqh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />lr/ain 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 />Rouqh Plumbinq <br />Final Gas Test <br />Meter Release t <br />FINAL -/zaltd a4qry4 I <br />Notes, Remarks, Etc.-./-v <br />Pemritee name (prinl):