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B!NG.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNI;R BUII,I)ER DI]I,CARAI'I()N <br />I hcrcby rllirnr undcr pcnally ot pcrjury lhal I am crcnrpl from lhc Conlrilck)rs' Liccnsc l-aw li)r lhc lolbsing rca\on (Ss.70-11.5 <br />llusincss and l'iol'cssion Codc): Any City or Counly which rcquircs n pcflnit to conslnlct. altcr. irTrovc. dcnxrlish or rcpair any <br />k) lhc froviqiilrs o, lhc Conlracn)r's Liccnsc(l Law (Chaplcr 9. (i)ilnilc[ciil8 wilh Scction T[XX) of Division -] ol lhc Busircss and <br />Prolis{ionsCodc)orthallrcorsheiscxctrrillhcrclionindthchasisforlhcrllcgcdcrcrrption. Anyiiolxli()nofScctionT0ll.5hyany <br />rfflicirolli)rxpcrtrlilsuhjcclsthc apflicrntk)acivilpcnnltyofnolil$rclhilnllvchundrcddollxrs($5(n). <br />_1. as owner of thc prcFrly, or my employEs wilh wagcs as lheir sh compensation. will do the work ord tlE stntctw ir rcl <br />intcndcd or offcred for sle (Se.7044. Busiress and Pmfessions Codc: The Conlractor's Liccns kw docs not .pply to an owner of <br />thc pmfErty who huilds or imprcws thcmn. ard who d@s sch wo.k himself or hcrself or thrcugh his or hcr own employces. <br />providcd thal such imprewmnts rc rct inlend.d or offcrcd for sb. lf, howew, the tuilding or ir{rovemnt is $H within ore }@, <br />of corphtk n, thc Owner Builder will havc lhe burdcn of prcving that hc or she did ret buiH or imprcre tlE tmtEty for thc purpos of <br />salc). <br />_1. ss owrcr of lhe rtropcfly. am cxclusively conlrectin8 wilh licensed contrucbrs to construct lhe pmjert (Scc. 7044. Busircss <br />ard PrrfssionCode:ThcContractor'sLiccnscLawdoesnotatplytoanownerofpropcnywhobuildsorimprovesthcreon. <br />and who sntrucls for such prcjccts wilh s ConlBclo(s) licenscd puFunt to the Contrsctor's Licens kw). <br />I rilr cxcnrnl undcr Sccti(rn_. B. & P.C. for this rcdson. <br />I);rls ( )$ ntr <br />WORKF'RS' COMPF'NSATI(IN <br />DECI.AS{IION <br />I herchy aflirm undcr penally of ptrjury onc of the following dslrations: <br />-lhaveordwillminlainaCenifrateofconsnlloSclf-lnsurcforworkers'ompension.ss <br />prcvkicdforbyS(tion3T0Oofthc <br />Libor Code. for thc pcrformrce of thc work for which the pcmit Ls issucd. <br />-l <br />have and will minlain workers' comlrcnsalion insurance. as requircd by Selion .]7OO of thc tabor Code. for the pcrfomrcc of <br />thc work lhis pcrmil is issucd. My conlpcrsulion insuroncc crricr ard F)licy numbcr sc: <br />Policy 9T-9D (62-l <br />-l <br />ccrtify thal in lhc pcrforroncc of lhc work for which this permit is issucd. I shsll nol cmploy any [ENon in any monrcr <br />m as to bcorc suhjccl to lhc workers' compensation lsws of CaliforniB. and sgEe thal if I should bccom subjcct to lhe <br />workers'comtEns.lionpmvisionsofSeclion3T00ofthct tDrCodc.lshall.fonhwilhcomplywithlhospmvisions.. <br />WARNING: Foilurc to rccurc workcrs'compcnsation covcragc is unlawful. and shall subject an cmploycr lo oiminal lEmlties [nd <br />civil fincs up lo onc hundrcd thousond dollars ($100.000). in hn to thc cost of compcnsation, danmgcs as providcd for thc <br />,?z- <br />I hcrcby alfirm under pcnnlly of pcrjury thiit I am uo(icr of C-hrptcr 9 (comnrncing with Scction 7Un) of Divisim .1 <br />of the Busircss ild Pmfessions Code. and my license is in full force ard €fftrt. <br />c 6Liccnsc <br />W <br />I hcrcby affirm undcr penalty of Frjury thst thcrc is I @nslruction hnding agercy for the pcrfomrcc of th€ work for which this pcmit is <br />issued (Sec. 3097. Civ. C.). <br />Lcndcr'. Addrc*.: <br />APPLICAN'T DFCLAR,4.TION <br />I lm'by aflinn under frcnalty of perjury one of lhc following dcclarations: <br />Dcrmlitioo Permils-Ashcsbs Notification Fedcral Rcgulations (Titlc 40. P{t6) <br />-Rcquircd <br />lrllcr of Notification <br />_l ccnify thal lhc fedcral rcgul0tions rcgtrding asbcstos rcmoval arc not applicablc b this p(Ect. <br />-l <br />ffiify that I havc read this applicalion ard stalc thal the ltbvc informtion is comt. I rgrc to comply with all City and County <br />ordiilDccs 8nd St8lc ljws rclating to aulh(,rizc ofthis Cily and Counry to cnts uF)n lhc <br />lbovc runtiotrcd propcfly for <br />Applicatrt or Agrnl <br />PemllE trame l'( <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Etuildinq Sewer <br />Area/Storm Drain <br />lnterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <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 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 rl <br />FINAL t\tqYto TT,kttno ..*n <br />Notes, Remarks, Etc.\r <br />Dste:.t-9,_ <br />Dtrtel <br />lf,rder's Nam: <br />1,-t- <br />,,r l/'>>1, <br />---------1------