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PLUM BING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS Oms-Buildq Dshatior <br />I hcrcby affirm undcr pcmhy of perjury d[t I m dcmpt form thc Conrnctort' Liccilc hw for thc following roon (se.7031.5 Buincr <br />md Profsrion Codc): Any City or County which rcquile a p$mit to @BtruG, ahs, improvg dcmolirh or rcpri, my sructuc, prior to it! <br />issun€, rbo r.qut6 the rpplient for such psmit to file r 3igncd rtrtmcnt d[t hc or 3hc is liccrocd purswt ro thc prcvilioa of thc <br />Conmdor'r Liercd hw (Chrpt6 9, CommctrcinS with Selion 7000 of Divilion 3 of thc Buiaor ud ProfalioB Codc) or dBt hc or <br />thc i! dcmpt rhdcfrom rnd thc be!i! for thc rllcgcd ccmption .Any violstion of Sction 7031.5 by uy rppliu! for r pmir lubjcct! th! <br />sppliqnt to s civil peulty ofnot morc thln fivc hundrcd douln ($500). <br />_1, I omcr of thc propcrty, or my cmploye with wagc as thct rolc smpcilatior! will do thc work and thc ,tructuc ir mt iiladcd <br />or offcrcd for sale ( Src.7044, Buinss End Profcrsions Codc: Thc Conusctor't LieBc Lrw do* not apply to m omr ofthc propeny <br />who builds or improve thooq aad who doc ruch work hiruclf or hanclf or tlrough hic or hcr om cmployc, providcd thrt tuch <br />improvcmenB are not intcndc! or offqcd for sle. If, howcB, thc building or improvcmcnt i! told whhin onc y@ of omplstior\ thc <br />Omcr.Builder will hEvc thc burdcn of provinS thst hc or ihc not build or improvc for thc purposc ofslQ. <br />_1, u omer of thc propcny, rm qclurivcly ontrding with liccrued onhdoru to @Etrud thc prcjcct ( Se. 7M4, Buinsr ud <br />Profe$ion Codc Thc Contn6or's Li@roc law do6 not lpply to u oma of propcty who builds or implovq thd6n , ud who <br />@nmm for such projccb with a Contrsctor(s) liccnscd purrunt to thc Contractor's Liccnsc lrw.). <br />_l sm cxcmpt undcr S€tion & P.C. for thi! rson. <br />Drtc: Omcr: <br />W <br />I hucby afrum undcr pcmhy ofpcrjury onc ofthc following dcclantioro: <br />_I hrrc sd will mintrh r Ccnfiiltc of Corocnt o Sclf-Irouc for worko' ompcutioq u provided for by Scction 3700 of thc <br />hbor Codg for thc prforrone of thc work for which thc pomit is irlucd. <br />_l havc and will maintlin workd' @mpcmtion insurEncc, u rcquircd by Sceion 3700 of thc kbor Codq for thc pafomne of the <br />work for this permit i! issued. My @mpcnstiotr iruurane erricr and policy numbcr arc:5 <br />Policy 1 o 1 l-L- l-oa <br />(Thh lcstion not bc @mplctcd if thc porit i, fo, On. hundr.d do[.. 1$l Oq oi fo4 - \ <br />_I @nify thlt in thc performne of the work for which rhit pcrmit i! i!!uad, I shrll not mploy any pmon in rny mmcr to s to <br />became subjcd to thc workcrs ' @mpctrsstion lsws ofCslifornia, md tht if I should becomc lubject b thc workcru' <br />compcnstion provisiont ofScdion 3700 ofthc hbor Codc, I shall,provisions. <br />-1_tu-11 <br />WARNING: Fsilurc to ssurc workcrs' <br />fine up to onc hundred thousnd dollars <br />@mpcBrtion <br />($l 00,000),in <br />covcngc is unlawful, md <br />addition to thc cost of compcution, <br />the labor Code, intcrert and anorney's fce. <br />LICENSED COT{TRACTORS DECLARATION <br />I hcrcby affirm undcr peuhy ofpcrjury that I m liccnicd undq provirion ofChaptcr 9 (ommcncing with Scaion 7000) ofDivirion 3 of <br />thc Butincs! and ProfsrioN Codc, End my liccroc is in full force ud cffcct.Dlg) 5\Liccroc Clals:VB Liccnsc Numbct <br />Datci \6fi (-l r"\^,( d:- <br />CONSTX.UCNON LEIYDING AGEIICY <br />I hscby aflum cnd6 pc8lty of ptrjuy thlt thqc i! s @6truc1ion hnding rgcncy for $. psfomnc of thc work for w{rich thir pemh ir <br />isucd (Sc. 3097, Civ. C.). <br />l*nds'r Nrmc: <br />Lcndcr'r Addrcss: <br />APPLICANT'S DECLARATION <br />R.guhtions (Thle 40, Psn 6)Dcmolition Permitr-Aibcator Notification Fedcrsl <br />_ Rcquircd ldtd of NorifiorioD <br />_l ccrti$ ttut thc fedcnl rcguhtions regarding sbsto! rcmoml arc not applioblc io thir projca. <br />_ I ccrtiry tirr I lLvc rad this eppliction snd ilstc dlt thc lbow hformtion i! 6ret I sgr6 to smply with rll Cilty rnd Couaty <br />ordiruncs rnd Stltc hw rolating to building corotsclion, snd hcrcby ruthorirc rcprccntltivcr of this City lnd Couty to 6tq upon tho <br />rbovc mcntioncd <br />Appliqot or agcnt <br />oo -2)Pcrmitte mmc (print): <br />purposcs. <br />a, <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-trap/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 Sewer/Cap <br />Back Flow Device <br />Rough Plumbing '.'11'07 ,rt* <br />Final Gas Test <br />Meter Release <br />FINAL 6,//111 .%rt; <br />Notes, Remarks, Etc.