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,,-./*u, *o-r NSPEcToR R EcoR D <br />APPROVALS DATE ID/SIG.COMMENTS oIVNT]R BIIILI)ER DT]I,CARA'IIoN <br />I hcrchy allirnr uildcr pcnally of pcrjury lhrl I anr cxcillll iiotrl lhc Conlrilckir\' Liccnsc Lrw lirr lhc folk)wing rcrson (Scc.7o.ll.5 <br />llusincss aril P()lisskill Codc): Any Cily or County which rcquircs n pcrillil lo conslnrcl- ahcr. irnprrrvc. dcntrrlish or rufnir any <br />sln,clurc. prior k, its issunncc. dlso rcquircs lhc alplicdll li)r such lrrnlil k) lilc a signc(l {lnlcrrcnl lhrl hc or shc is liccnscd pursurnl <br />nr thc pnrvirirrns ol'lhc (-'onlrrckr's l-iccnse(l hw (Chanlcr 9. Cornilrcncing wilh Scclkln 70{X) of l)ivision J of thc Busincss and <br />I'rolcssionsCodc)orlhathcorshciscxcnrptthcrclionrrrdlhcharisforlhcrllcgcdcxcnrption. Anyvk)hlionolSc.tionT0.]l.5hyilny <br />xpplicaillli)rrpcrilrilsubjcclsthc applicrnllorcivillc0ahyolnoltrrcrclh!trllvchundrcddollars($5(X)). <br />-1. <br />as owrcr of thc prcFrly. or my cmployces with wages as lheil slc @mpensation, will do thc work ud the strutw is nol <br />intendcd orofferedforsle(S(.T044.BusinessmdPrcfcssionsCodc:TheContractor'sLicen$lrwdocsnotapplyloanowrerof <br />thepmpcny whobuildsorirprcuthcmn.atdwhodessrchrcrthimselforhcmlforthrcughhisorhcrowncmployees. <br />providcd th.I such imlrercmnts e mt inteldcd oroffercd for sh. lf. howevtr the boiHing or inprcvcmnt is sH within one }{U <br />of otr{,btion, thc Owrer Builds will hlve the burdcn of prcving that he or she dil rct hrild or itr{,rove thc prcFrty for the purpoc of <br />sh). <br />_1, as owncr of lhc po[t,ty. am cxclusivcly conlracling wilh licenscd contractos lo conslrucl thc prcjcct (Scc. 7044. Busincss <br />and Pmfssion Code: Thc Conlractor's License Law docs not apply to an owner of prolrcny who builds or improves th6sn. <br />and who contGcls for such prcjccts wilh a Conlmclo(s) liccnsd pursuanl lo lhc Conlraclor's Liensc law). <br />_l um cxcnrpt undcr Scction-. B. & P.C. lor lhis rcason. <br />Drte:- O*trer:- <br />--WORKFRS' COMPENSATION <br />DECI.ARATION <br />I hcrcby aflirm undcr pcnally of pcrjury onc of lhc follow ing dcclualions: <br />Lrtarr (ixlc. lor lhr'pcrlitrillxlcc i)l thc $o,k lirr shich th0 pcrtrrit i\ i\\ncd. <br />-l <br />have <br />the work <br />and qill mainlain workers'Scclion 3700 oflhc Lntx)r Code. for the pcrfornuncc of <br />which this is issucd.carier and policy numbcr m: <br />6Ar <br />Y <br />Policy cs J ilt / >o <br />_l ccnify thal in lhc Frformnce of lhc work for which lhis pcrmjt is issued. I shall not employ any person in any manncr <br />$ as to hccomc suhjccl to the workers' compcnsution laws of California. and agrcc that if I should tKom subjcct lo thc <br />workcrs'comlrcnsalionpmvisionsofScclionSTU)oflhcLrklrCodc. lshall.fonhwilhconplywithtlpsJ,rcvisions.. <br />WARNING: Failurc to surc workers'compcnsation covcra8e is unlawful. and shall subjecl an employer to simind pcnaltics and <br />civil fincs up to orc hundrcd thous&nd dollars in addition to thc compensation.$ providcd for thc <br />Scclion 3076 of lhe inlcrcsl fccs. <br />-[(l( <br />I hcrchy affirn unrlcr pcnalty ofpcrjury that I am 9 (commncing with Scction 70OO) of Division -l <br />of the Business ald Profcssions Codc. and my liccnrc is in full forcc and cffect. <br />c3() <br />l-iccilsc <br />rq <br />I hcrchy allirm untlcr ;rcnalty of pcrjury lhal lhcrc is a consldclhn lcndirrg agcncy for thc pcrlbrnhncc of thc work lbr Bhich thi\ Jrrillit is <br />issucd lScc. .1097. Civ. C.). <br />[-cndcr's Ndilrc: <br />[rndcr's Addrcss: <br />APPLICAN'T DECI,ARA'I'ION <br />I herthy aliirm unrlcr pcnnlty of pcrjury onc of thc folkrwing dcclrrations: <br />l)cn()lilir)D Pcrnrits-AshLslos Nolificrlion lrcdernl Rcgulalhns ('l illc {0. Pxn6) <br />_Rcquircd Lcltcr of N(nillcation <br />-l <br />ceaify that thc fcdcr8l rcgulalions rcgsrding asbcstos rcmval are not spplicsble to this pmjcct. <br />-l <br />ccnify lhat I hove rcad this Bpplicatbn and slstc that lhe atnvc informution is corrct. I agre to comply with all City and County <br />ordinarces and State hws rchtirg to construclion. arxl hcreby suthorizc reprcscnlalivcs ofthis City and County to ents ulDn thc <br />atxrvc mnliorcd propcrty for <br />Applimnt or Agetrl <br />lDrrnrilet ntrnr( <br />s?7-1-- <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 Piping <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rouoh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />N/ain DrainiPool Pipinq <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitarv Sewer/Cap <br />Back Flow Device <br />Rouqh Plumbinq <br />Final Gas Test <br />Meter Release <br />FINAL 'l-r1 ao b*rat L# s< <br />Notes, Remarks, Etc. <br />n. Lc,2- <br />*,", ,l(b>/4