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PLUMBING.INSPECTOR RECORD <br />APPROVALS DATE IDiSIG.COMMENTS OWNER BUILDER DELCARATION <br />I herchy amrm undcr Fnalty of tErjury thal I m excmpt fiom thc Contractom' Liccns hu for rhe following *n*niS*.1;.li.S I <br />Busincss and Profcssion Code): Any City or Counly which rcquircs a 1rcmit Io construct. oltc. improve. dcmlish or Epair any <br />struclurc. prior lo ils issuarce. also rcquires the applicsnt for such lrrmil lo filc a signcd statcmnt thal hc or she is licenred pusanl <br />lo the prcvisions of thc Conrsctor's Liccnrcd tiw (Chapter 9. Commncing with Setion 7000 of Division 3 of the Busircss and <br />PrefcssionsCode)orlhalhe orshcisexcrplthmtromandlheb6sisforthcslhgcdcrcmption. AnyviolationofSsrionT03l.5bymy <br />applicant for a pcrmit suhjccts lhc applicant to a civil penalry of nor mrc than fivc hundred dolltrs ($500). <br />-1. <br />as owncr of the prctrdy. or my cmployes with wages as their ole conrpcnsrtion. will do thc wo* ard the stndre is ml <br />inlefrrcd oroffercdforulc(Sa.?O44.BusiressmdPmfessionsCodc:ThcContrsctor'sLiccnrckwdoesnolapplytoanownerof <br />lhe pmFny who builds or itr{rmws theon. and who des such work himsclf or herslf or thmugh his or her own employecs. <br />providcd that such improvcmnls rc mt iilended oroffcEd for ele. ll, howcvcr. lhe building or inprorcmnt is sld wilhin one fu <br />ofcomphtion. lhc Owncr BuiHs will hsve the burden ofpmving that hc or shc did not build or impmvc tie pmpcrty for the purpos of <br />slc). <br />ilrrl wh() c()nlncl\ li)r such pr(lccls wilh a Corilraclor(c) liccnsc(l pursunill lo lhc (i)nlrict(il \ l-iccn\c l-r!v). <br />-l <br />m excmpl undcr B. & P.C. for this rcrson. <br />lrntc: <br />WORKERS' CO]\IP}'NSA'I'ION <br />DECLAIL\1'ION <br />I hcrehy uffirm undcr penalty ofperjury onc ofthe folloping declarations: <br />l,ahor (iilc. li)r lhc pcrlirrnurcc ofthc rvork for which thc pcrilril is issuc(j. <br />_l havc and <br />lhe work for <br />will nuintain Sslion 3700 of lhe ljk r Code. for the pcrforroncc of <br />lhis caricr aml Jxrlicy nurntrcr arc: <br />o vl <br />3/t />oPolicyt3e <br />-l <br />ccnify lhal in lhc ,rcrforrorce of lhe work for which this permil is isscd. I shall not employ any Frcmn in rny rmrcr <br />s ai to bc@m subjel to thc wortss'compcnsation laws of California. and agrcc thot if I slpuld bccore subjst to thc <br />workss'comlf,ns.lionpmvisionsofScction3T0OoflhetitnrCode. lstull.forthwithsmplywithlhospmvi3ions.. <br />WARNING: Failurc to surc workcrs'comJrcnsalion covcmgc is unlawful. ond shall suhjcrt an cmploycr lo oiminal 1rulties and <br />civil fircs up to onc hundrcd thousand dollm ($l tn lo lhc compcnsution. damgcs as providcd for thc <br />Sccti(rr <br />Yi <br />of lntnr Code. iotcrcst and>> <br />I hcrchy atfirnr undcr pennlty ofpcrjury that I am licenscd undcr provision Chaplcr 9 (commncing with Scction 70OO) of Division 3 <br />of lhc Busincss and Professions Codc. trd my liccnsc is in full forcc md clTcct. <br />[-iccnsc c36 L{ <br />t 4. <br />irruccl (Scc. -1{)97. ('iv. C.). <br />I.cnrlcr'r Nrm:: <br />lxndcr's Addrcss: <br />APPLICANT DECLARATION <br />I herdry alfirrn undcr pcnalty of pcrjury onc of the [olk)wing dcclarationsl <br />Dcntr)lilion I'crillils-A\hcslos Nolilicalion Fcdcral Rcgulations (Tillc 40. Pan6) <br />_Rcquircd [-cttcr of Notilication <br />-l <br />cslify lhal thc fcdcml rcgulations rcgsrding asbcslos remval m not 0pplicabh to lhis pmjcct. <br />_l ccflily that I havc rcad this ard stale thal lhc atbve informtion is conccl. I agre to comply wilh all City and County <br />ordinanccs snd Statc hws ofthis City and Counly lo entcr upon the <br />abovc [E[tioncd pmpcriy for <br />Applicort or Agenl <br />l'emrilee nome { <br />and <br />l)ote: <br />UNDER GHOUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf loor <br />Building Sewer <br />Area/Storm Drain <br />lnterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Piping <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 <br />FINAL 7 n -7,b&nnc 1*&q <br />Notes,,Remarks, Ftc.ll <br />t4 l1-It -clrL ),-fiOaz#''t'? <br />ru <br />I)ille: