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PLUMBING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hereby aflirm undcr pcnalty of fErjury that I m excmpl ffom the Con(racloN' Licens [:w for lhe following rcasn (Ss.70.11.5 <br />Busincss and hofcssion Code): Any City or County which rcquires a ;rcrmit to @nstrucl. alts. improve, demlish or rcJrir uy <br />struclurc. prior to ils issuarcc, also rcquircs lhe applic.nl for such frcrmil lo file a sigrcd stalemnl that hc or shc is liccnsd pusuont <br />lo thc pmvisions of lhc Conlractor's Licen*d hw (Chaptcr 9. Comcming with Section 7000 of Division 3 of the Busincss ud <br />Ppfcssions Codc) or that hc or shc is cxcmpl lhcrcfrom and the b6sis for thc alleged cremption. Any violation of S(tion 703 I .5 by any <br />applicant for a pe.mil subjects the applicant to B civil penalty of not mre lhan five hundred dollus ($500). <br />-1. <br />os owner of lhe prcJErly, or my emploFcs with wogcs as thcir solc compcnsation. will do thc wok and thc structw is mt <br />intcrded oroffcrcdforslc(S€,T044,BusincssandPmfessionsCodc:ThcContrsclor'sLicensehwdresnotspplytoarowrcrof <br />lhe pmFny who builds or inpmrcs themn, and who dcs mh work himself or hcrElf or thrcugh his or her own employcer. <br />provided lhat such imFovemnls rc rct inlcndcd or offercd for sb. If, howcv6. thc building or ir{,mrerent is sH wirhin orc F{ <br />of or{,htion. the Owrer Buikler will harc the burdcn of pmving thd he or shc did ml huild or imprcrc the prctEty for tlE purlDs of <br />sle). <br />-1. <br />as owner of the pmpefly. amexclusivcly conlracling with licensed contraclos to mnstrucl thc proFct (S4. 7044. Busiress <br />and ProfesshnCodclThcContraclor'sLiccnseLawd@snotapplytomowncrofprcff,rtywhobuildsorimpmvesthermn. <br />and who conlmcts for such ImjcTts wilh a Contmcto(s) liccnred pursuail to lhc Conlraclor's Lhcns hw). <br />I amercmDt undcr Sstion . B. & P.C. forthis reason. <br />Dale:_ <br />!VORKER.S' C()I\IPENSATION <br />DECI.ARA'I'ION <br />I hcreby affirm undcr pcnalty of lujury orc of thc following dccluations: <br />-l <br />hrvcaildNill niriilrhlrCcnitlcilcol-Conscilk)Sclllnsurclirrworkcrs cornpcnsrtion.ns provi(lcdforbySccti(rn37(nofthc <br />Lahor (ixlc. lirr thc pcrlbnnnncc of lhe work lor s'hich thc pcrmit is issuc(I. <br />-l <br />havc and will minlain workcrs'compcnsation insurarcc. ss rcquircd by Scction 3700 of thc tihor Code. for thc pedormrce of <br />lhc s'ork rhi\is issucd. My workcrs'insurancc cari6 erd lFlicy number ue: <br />t\ <br />1Yt r>oPolicy,3 <br />-l <br />ccnify lhat in lhc pcrformrcc of lhe work for which this [rcrmil is issucd. I shall not cmploy any pcrson in any manncr <br />s as to bccom subjat to lhc workcrs'comlEnsation laws ofCslifornio. and agrcc that ifl should hccorc subjcct to thc <br />workcrs'compensalionprovisiousofScclion3Tfi)ofthchb()rCodc.lshall.forlhwithcomplywilhthoscpmvisions., <br />WARNING: Failure to $cure workcrs'compensalion coveagc is unlawful. and shall subjcct an employer to siminal tmaltics md <br />civil fines up to onc hundrcd thousond dollars ($100.000). in addilion to the cost of daroges an pmvidcd for the <br />Scclion .3076 of thc inlercst and fccs.Lll q <br />I hcrehy rlfirrl undcr pcnalty of pcrjury lhal I am liccnscd pmvision of Chaptd 9 (commrcing with Section 70OO) of Division 3 <br />of the Business and Profcssions Codc. and my license is in full fore and effcct. <br />Liccnsc 'f36 <br />q <br />I hcrchy affirnr undcr frcn.hy of pcrjury that therc is d conslrucli(rn hnding agcncy for lhc pcrfomance of thc work for which this Jrrmit is <br />issued (Scc. .1097. Civ. C.). <br />hndcr's Namc: <br />Lcndcr's Addrcss: <br />APPLICANT DECLARATION <br />I lErhy allinn undcr pcnillty of pcrjury onc ol thc follo$ ing dccluralionsl <br />l)cnr)lilion Pcrilrits-Ashcslos Nolificnlior Fcdcrll Rcgulalio0\ {-Iitlc 4{). Purt6) <br />_Requircd lrtlcr ol N(ilificrthn <br />_l ccnity lhal lhc fcdcrulrcgulations rcgarding asbeslos rernovalarc not applicablc lo this pmjNt. <br />-l <br />ccrlify thal I hsvc read this applictrtion ard statc lhal lhc abovc informtion with oll City and County <br />ordinarces and Stale ljws rclatirg to hcrcbv aulhorizc <br />i\ corrccl I rgrcc lo contply <br />' rcprc{cntrtives of rhi\ Cily enlcr ulmn lhc <br />ak)vc nrcnlioncd propcrly for <br />Applicant or AgeDt <br />---/h.z <br />and <br />t4 <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />lnterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rouqh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />Main 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 />Fina! Gas Test <br />Meter Release I <br />FINAL lltq '7/)ra* nn r Lbffi <br />Notes, Remarks, Etc.lr <br />, <br />t?-t((q-r (L -Dt*Y)6L*f? <br />t I I t' <br />Dsle: <br />Pemile trame (prinl):