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Owner-Builde, Dccl8ration <br />I hacby affum undr pcuhy of pcrjury tlut I m acmpt form thc Contactoru' Lieroc lrw for the following roon (se.7031.5 Bwinqr <br />ud ProfBsion Codc): Any City or County which requtc a pcrmit to @nstrucl, alt6, improvq dcmolish or rcprir uy structuc, prior to ia <br />issune, also rcquira thc appliont for such pqmit to filc a ligtrcd ltrtmcnt thst hc or shc is liceucd punwt to rhc provirioc of th€ <br />Contrsctor'! Li@6cd lrw (Chsptq 9, Commcndng with S@tion 7000 of Divilion 3 of thc Buiner and Profqsioro Codc) or that he or <br />she i5 qcmpt thqcfrom rnd thc b.si! for thc 8llcgcd qemption .Any viohtion of S@tion 703 1.5 by any .ppliont for a permh rubjc* rhc <br />sppliqil to r civil peulty ofnot morc thrn fivc hundrcd dollars ($500). <br />-1, <br />8s oMcr of thc property, or my cmploya with mgc $ thcL solc @mpcn$tior\ will do thc work md the rtrudurc is not intqded <br />or offercd for $lc ( S@.7044, Bulin6i and Profc$ion! Codc: Thc Conll.clor's Licsc lrw doB not rpply to u om6 of the prop€fty <br />who builds or improv6 therco[ ud who doo ruch work himself or harclf or tkough his or hcr om cmploye, providcd thar ruch <br />improvcmcoG rc not intcndcd or offscd for slc. If, howevq, thc building or improvcmcnt it sold wihin onc yar ofcomplaio4 thc <br />Omcr-Buildcr will hrvc thc burdcn ofprovinS rlEt hc or shc not build or improv. fo, the purpose ofslc). <br />_1, 6 omcr of thc propsty, sm dclusively ontracing with liccNtrd @ntrlclor6 to @Ntruct rhc proj@t ( Ss. 7044, Buinss ud <br />Profsioo Codc: Thc Contndor's Liemc hw do6 not lpply to rn oMd of propsty who buildr or improva thcr@n , cnd who <br />contrEcB for cuch projctr with a Contraaor(!) liccolcd pur6urnt to thc Contrrctor's Licenlc l{w.) <br />_l am cxempt undcr Smion _& P.C for this rason <br />Date ( )s ncr <br />WORKERS COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: <br />_l have and will maintain a Certifiete of Co$ent lo Self-lNure fo. workers' compensation, as provrded for by Scction l7o, of the <br />t:bor Code, for the performance ofthe work for which the permit is rssued <br />_l have rnd will mrintlin workct!' @mpcution insur.tre, 6 rcquircd by Scction 3700 of thc bbor Codg for thc pcrformr e <br />work for which this pcrmit is issued. My workcrs' compcmtion inlurane enicr and policy number arc: <br />ofthe <br />\ <br />Crrrier: _ _ <br />1co6s od/qrln anPolicy <br />(This srction nced not bc complctcd ifthe permit is fo. One hundred dollars {S100) or lqs) <br />-l <br />cenify thrt in thc pcrformance of the work for which this p€rmit is isrucd, I shall not mploy any pason in any mrnner ro a! to <br />beamc subject to thc workers ' ompcnstion hwE ofCslifornia, rnd agre that ifl rhould becomc subjea ro the workcrs' <br />competr$tionprovisionsofSation3700ofthet borCodqIshall,fonhwithomplywiththoscprovisions. <br />WARNING: Failure to s@utc workcrs' @mpcrostion @vcrrgc is unlawful, and rhall cubjct rn cmploycr to oiminal pcultio and civil <br />fine up to one hundrcd thousrnd dollarr ($100,000).in addhion to thc ost ofompcnsltion, d!rog6 I providcd for thc Scciion 3076 of <br />lhe lrbor Code, interGt and rttorney's feq. <br />LICENSED CONTRACTORS DECI.ARATION <br />I hcrcby aIfirm unda pculty ofpcrjury thlt I m lieNrd undcr provirion ofChapto 9 (@mmencing with Scction TOOO) ofDivision 3 of <br />thc Bsin$s and ProfssioB Codc, snd my liccme is in full fore and effa. <br />t.iceueclass R Cfc-sS <br />-t.i".n".N"^v", <br />15.A!l LA <br />C vv,,lR,.. lr]ter < l.nnDate:4J <br />CONSTRUCTION LENDING AGENCY <br />I heeby affrrm undcr p.Ehy of p€rjury that there is a @Etruction lcnding agency for thc performnce ofthe work for which this pcrmit is <br />issued (Sec. 3097, Civ. C.) <br />l-ender's Nrme <br />I-ender's Address <br />APPLICANT'S DECLANATION <br />Demolition Ptrmits-Asbcator Notification Fcdcnl Rcgulrtions (Thlc 40, Pan 6) <br />_ Rcquircd Laro of Notifiqtion <br />_l ertify thst thc fcdcr!l ,cgulatioa regdrding rsbetos removal are not applioble to thi! project <br />_ I certify thlt I hsve rad thir applietion rnd state tlut the rbove irformation is corrrcl. I igrce to @mply wi$ rll City and Counry <br />ordimncq and Statc lJw rclrting to building @Etruction, .nd hcrcby ruthorizc reprscntltivcs ofthis City and County to enter upon thc <br />above mentioned propcrty for PUrPoSeS. <br />Applionl or agent sig <br />Permitte mmc (print):Lnc.^s uJalb <br />APPROVALS DATE ID/S!G.COMMENTS <br />UNDER GROUND <br />Waste & Vent <br />Water-Underfloor <br />Gas-Underfloor <br />Building Sewer <br />Area/Storm Drain <br />I nterceptor/ Clarifier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Pipeing <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOUSPA <br />P{rap/Drain Line <br />Main Drain/Pool Piping <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Misc <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary SeweriCap <br />Back Flow Device <br />Rough Plumbing ?-\\Ll\ \M <br />Final Gas Test l't I <br />Meter Release <br />,//r\)FINAL {lE/ / | <br />Notes, Remarks, Etc./ 'l '-: <br />M:\WP51\P6rmit-lnspection Foms\Plumbin0-lnspector <br />PLUMBING-INSPECTOR RECORD <br />Date z-/ql-,_-tpptio,r., Lvzcrs {ll.) -114, <br />-o,r" 46//fi-