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p,iluM erNc-rNSPEcroR REcoRD <br />APPROVALS DATE ID/SIG.COMMENTS oWNI'R BIIII,I)I.:R I)ET,CARA ION <br />I hcrch;- allirm undcr pcnally of pcrjurl'that I ilm cxcmpl lion lhc Conlrrck)rs l-iccnsc l]rw for the lirllowing rcason (Scc.70-11.5 <br />Busincss rnd Proltssion Codc): Any City or (i)uilly $hich rcquircs l |--rnrit to conslnrct. ahcr. irrurovc. dcnrolish or rupair dn!, <br />slrucluc.priorloil\ i\(unncc.alsorcquircsthcnpplicrntli,rsuchpcrmitk)filcxsigncdstrtcilrcnt thathcorshcisliccnscd pursuanl <br />h lhc f()visi{)ns (,f lhc Conlrrclor's l,iccnscd l,ilw (Ch{plcr 9. (bnrncncing with Scctk)n 7(X)0 of Division 3 o[ thc Busincss and <br />Proltssions Codc) or thill lr or shc i\ cxcnll, lhcrcliorn xnd thc hrsis lbr thc allcgcd cxcmprion Any viohtion (,fseclkrn 701 I 5 by any <br />applicrnt li)r a fcrnril \uhjccts lhc applicall nr r ci!il pcnalt!, of not nDre than ll!c hundrcd dollurs (S5(X)). <br />-1. <br />us owncr of thc proFny. or my employss wilh wages ds their sle compcnsstion. will do the work ud thc strctm is rct <br />intendcd oroffcrcd for sle (58.7044. Business and Professions Codcr Thc Contractor's Licensc lrw docs not apply to an owncr of <br />thepmFny whoboildsorir{rovcsthemn.atdwhodcsMhworkhimselforherslforlhmughhisorhcrownemployccs. <br />previded lhrt such inprcrcmnls rc rcl intcnfu or olTcrcd for sh. lf. howew. the hriHing or ir?rcvemnl is sH wilhir ore,sr <br />of @r{tlction, the Owrcr Builder will h8w thc burden of poving thal hc or she dil mt build or itrpmrc th€ pmfraty for tlrc purp* of <br />slc). <br />-1. <br />as owncr of lhc prcpeny. am cxclusively contracling wilh liccnsed contraclon to construd thc pmjed (Ss. 7M4. Busincrs <br />and PrcfursbnCode:ThcContraclor'sLicenscLawdmsmtapplytoanowncrofpmpenywhobuildsorimprcvesthcrsn. <br />and who controds for such Jrojccts with a ContEcto(s) liccnsd pursu&nt to thc Contraclor's Licens kw). <br />_l lnr cxcrilpl under Scction_. B. & P.C. fbr this rcason. <br />Dale: _ Owner: <br />WORKERS' CONIPENSATION <br />NECLARATION <br />I hcrcby aflirrn undcr pcn0hy of perjury onc oflhc lblhwing dcclarations: <br />l hrlc rnd s'ill nEinl;rin il Ccflificalc ol Coilscil b Sclin\urc lirr $rrrkcrs' conrpcnsarion. r\ providcd li)r hy Sccrion .lT{X) ol lhc <br />Lahor (ixlc. Ibr thc pcrlilrnrxncc ol'lhc work for which lhc pcriltit is issucd. <br />_l havc <br />lhc work <br />and will nrainlain workcrs'compcnsntion insurancc. as by Seclion 37U) oflhc labor Codc. for thc pcrformnce of <br />lirr whiclt is isscd. My ctrrcr numhcr arc: <br />Policy L5 <br />-l <br />ccrtil,v lhrt in lhc l)crlirftnancc r), lhc trr)rk lirr $ hich lhi\ l)crtrtit i\ isrrcrl. I shall not cntphy anv pcrson in rn) nHnocr <br />so i\k)tf,'conrc\uhjcclk)lhcrvorkcrs'(onipcnsxtionhw(o[Cnlilirrnia.antlagrccthatiflshouldhcconrcsuhjccththc <br />workcl( eonlPcIsillioil p()visioils ol-Scclion .l7(X) ol lhc Lrhrr Codc. l shall. linlhwith conlply wilh lho\e provisioils.. <br />WARNING: Failurc lo su.e workcrs'@mpensalion covemgc is unlawful. and shall subjcrt u emplolrr lo ciminal lErutties and <br />civil fincs up Io orc hundrcd thousnd dollars ($100.000). in lhc cost danugcs as provtlcd for lhc <br />Scclion 3076 oflhe Lahr intrrc\l rnd s fccs. <br />I <br />I hcrcby affirm undcr pcnolty of pcrjury thot t am under provision 9 (commcncing wilh Scclion 7000) of I)ivision 3 <br />of thc Business and Prolcssions Codc. and mv liccnsc is in flll forcc and el-lccl. <br />Liccnsc I {o ( <br />issucd (Sff.3097, Civ. C.). <br />bnder's Narc: <br />[rndcr's Address: <br />APPLICANT DECLARATION <br />I hcrctly lllimr undcr pcnilhy of pcrjury onc of lhc tblk)wing dcclarilt i(rls: <br />Dcnrolition Pcrmils-Ashcstos Nolillcation Fcdcrrl Rcgulations ('fitlc 40. Pad6) <br />_Rcquircd [-cltcr (rl Nolilicalion <br />_l ccrlify that lhc fcdemlrcgulstions rcgarding &sbestos Emvsl e rel applicable to Ihis prcjcrt. <br />_l ccnify that I havc rcud this application and statc that thc atnvc inlbrnlation is corcct. I with sllCityand County <br />ordinances and Slate kws rclatitrg lo <br />abovc mnliorcd proJEny for inspecl <br />Appli(snt or Agenl /Pemrile nsnre <br />building conslruclion.a!thorizc anrl to cnls upon lhc <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf loor <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 />It/ain Drain/Pool Piping <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 <br />FINAL ,1.ptw Plrvoeu *bq <br />Notes,;Rerparks, Etc. <br />l'?-llt ln - Cl rL .* yg <br />I lt <br />l)alr: <br />Dsle: <br />b*n/1*