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PLUMBING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS ()lr\l:R lll ll.l)l.R l)l:1.( \R 1 I I():,{ <br />I hereby aflirm under [Enalty of pcrjury lhal I m crcmpl ftom lhc Contraclos' Liccnse hw for the following rcBsn (Str.7031.5 <br />Business and Profession Codc): Any Cily or Counly which rcquircs a fremil to construcl. altcr, improvc. dcmolish or rcpair any <br />structurc. prior Io ils issuance. slso requires lhe applicant for such Frmit to filc a sigrcd statcrcnt lhat he or shc is licens{ pursant <br />to lhc prcvisions of thc Contractor's Licenscd [:w (Choplcr 9. Commcncirg with SNlion 7000 of Division 3 of the Busincss and <br />Prcfessions Codc) or that hc or she is exempt lhercfrom 0nd thc basis for thc allcged cxcmption. Any viotation ofScclion ?03L5 by trny <br />applicant for I lf,rmir subjccls lhe applicant to I civil pcnalty of nol rerc than five hundred doUes (9500). <br />-1. <br />as owncr of th€ prc[Eny. or my employees wilh wages as their solc compcnsalion. will do the wort and the strctw is not <br />inlcnd€d or offered for sh (S€.?(X4. Busircss and Prcfcssions Codc: Thc Contractor's Licens llw does not apply to an owrer of <br />thc polrdy who builds or improves themn. md who des such work himsclf or hersclf or lhrough his or her own cmphyees. <br />provided that such impmwmnts e ml inlerdcd or ofllred for sle. If. howcwr. thc building or ir{,mvcmnr is sold within ore }cq <br />of complction, thc O{ner Builder will haw tlrc burdcn of pmving thal he or she dii mt buik or irprcrc fE pmlmy for lhe purlbsof <br />sle). <br />-1. <br />as owncr oflhe p()pcny. am exclusively contracting with liccnscd contraclors to construct lhe pmtrct (Scc. ?044. Business <br />.nd PmfcrsbnCode:ThcContractor'sLicenscLawd@snolapplykranowncro[propcrtywhobuildsorimprovesthcrmn. <br />.nd who conlEcts for such prcjsts with a Crnlncto(s) licenEd lrursuut to lhc Conlrelor's Licens kw). <br />-l <br />amexempt under Section-. B. & P.C. for this rcasn. <br />-__._ Owner <br />WORXPRS' COIIIPENSATION <br />DECI ARATION <br />I hcrcby affirm under pcnalty of perjury onc of the tollowing delarations: <br />-l <br />havo and will nuinlain a Ccrtillcilte ol Conscnl lo SclLlnsure for workcrs conrpensation. ns prrvtlcd lt)r by Scction .17fi1 of lhc <br />titnr Ctrlc, for thc pcrfornrancc oflhc work ti)r which lhc 1trmit is issucd. <br />_l <br />thc <br />havc and will maintain workcrs' compcnsalion insurarcc. as by Setion 3700 ofthe tibor Code. for the [Erfomsncc of <br />i caricr urd policy numbcr uc:pcrmil is issucd. My comlEnsstion <br />Policy , <br />-l <br />ccnify that in thc perforroncc of lhe work for which lhis pcrmit is issued, I shall not employ any pcmon in uny ronncr <br />* astobecomsubjcctlothcworkers'smlrcnsationlawsofcalifomia.andagrcthatiflshouldbecomsubjsitothe <br />workcrs' compensation prcvisions of Scction 3700 of thc kbor Code. I stull. fonhwith mmply with ttnrc pmvisions.. <br />WARNING: Failure to slrc workcrs' compcnulion is unlawful, snd shall subjcct an cmplo)cr to riminsl Jrcnaltics and <br />civil lincs up to onc hundred thousud dollars in rddition b thc cort damges as provircd for lhc <br />Scclion 3076 <br />Dale: U 71vfr1 <br />'ilcrcsl and <br />I hcrcby aflirm undcr pcnalty of perjury lhat I anr under provision ofChaptcr 9 (comrcncing with Sccrion 7000) ofDivision 3 <br />of thc Busiress 8nd Professions Code, and my liccnw is in full fore and etT$t. <br />Z 6Liccnsc <br />Date:_ <br />coNs't Rt,c'il0N t,ItNDtNG ACt.rNC't <br />issucd (Ss. 3097. Civ. C.). <br />knder's Namc: <br />- <br />Lcndcr's Address: <br />APPLICANT IIECLARATION <br />I hcrcby allirnr undcr penalty of perjury onc of thc following dcclarltions: <br />Dcmolilion Pcrmits-Asbcsk)s Nolificnlion Fcdcral Regulalions (l itlc.l0. Pril6) <br />-Rcquirctl <br />lrttcr ol Notilicatk)n <br />_l c.rtify that rhe fcderalrcgulalions regarding asbcstos rcmvalare nol spplicsblc lo this project. <br />_l ecilily lhnl I Iravc rearl this rpplitali()n nn(l\trlc Ihtl tlE ahrr'c inlirrrrratiorr i\ c()rrccl. I wilh all City and County <br />ordinances and Slatc Laws rclating to <br />atnvc rrcntioncd propcrly for <br />Appllcant or Agent <br />Pemile nsme <br />und aulhorizc <br />Dnle. <br />aild <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 Pipino <br />Gas Pipinq <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 LineiBack 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 />Rough Plumbing <br />Final Gas Test <br />Meter Release <br />FINAL 4 tqw l)ftrul(\--*Yl <br />t\qteE, Rqmarks, Etc.,fTI <br />tLl lhl 14 c l(L 4rla-3n <br />I t (t <br />I <br />DBle: <br />I