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PLU rvfENAlNS PEcro R R Eco R D <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hereby affirm undcr pcnalty of Frjury thal I ar cxempt from the Contraclors' Licensc Law for thc following rcason (Scc.7031.5 <br />Busincss and Profession Code): Any City or Counly which rcquires a lrermit to construct, alter. improve, dcmlish or rcpair any <br />slructure. prior to its issumce. also requircs lhe applicant for such permit to file a signcd statcment that he or she is licensed pursuant <br />to thc provisions of the Controctor's Licensed Law (Chaptcr 9, Commencing with Scction 7000 of Division 3 of the Busincss and <br />Prct'cssions Code) or thal hc or she is exempt thqcfrom and the basis for the allegcd excmption. Any violation of Section 703 I .5 by any <br />applicant for a pcrmit subjccts thc applicant to a civil penalty of not more lhan five hundrcd dollars ($500). <br />-1. <br />as owner of the prclrcrty. or my employees with wagcs as thcir sole compcnsalion, will do thc work md the structw is not <br />intcndcd orolTered for salc (Se.7044, Busincss and Prcfcssions Codc: The Contractor's License Law docs not apply to an owner of <br />the prcperty who builds or improves thcmn. and who does such work himsclfor hersclfor through his or hcr own employees. <br />providcd that such improvcrrcnts tre nol intcndcd or offercd for salc. Ii howcvei thc building or improvcmnt is sold within one ,rd <br />ofcompletion. the Owncr Builds will havc the burdcn ofpreving that hc or she did not build or improve the pmFErty for thc purlbs of <br />sale). <br />-1. <br />as owncr oflhe propeny. am exclusivcly contr{cting with licensed contraclors lo construct thc prejcct (Sec. 7044, Busincss <br />and Pmfession Codc: The Conlractor's Licensc Law docs not apply to an owner ofproperly who builds or improvcs thcrcon. <br />and who conlEcls for such projects with a Contmcto(s) licensed pursuant to thc Contractor's Licensc Law). <br />_l iltrr cxcilllil undcr Sccli{rn_. B. & P.C. lirr thir rcnson. <br />WORKERS' COMPENSATION <br />DECLART{TION <br />I hercby affirm under pcnalty ofpsjury onc of thc following declarations: <br />-l <br />htvc and will nraiDlair u Ccnillcalc ofConscnl lo Scll:lnsurc lbr workcrs' cotrUcnsalion. rs providcd lbr by Scction 3700 ofthc <br />t-rhor Codc. li)r lhc pcrlonnilncc of lhc work for which thc pcrDit is issucd. <br />-l <br />have and will mainlain workers' compcnsation insurancc. as required by Section 3700 of the Labor Codc. for the perforroncc of <br />the work for this is issucd. My workcrs' compensalion insurancc caricr and ;nlicy number uc: <br />Policy 36>7o <br />_l ccnify lhat in thc perfornuncc of the work for which this pcrmil is issucd. I shall not cmlloy any person in any manncr <br />so rs lo bccorrc subjcct to thc workcrs' compcnsation laws of California. and agrcc that if I should bccorre subjcct to thc <br />workers' comlrcnsatit)n prcvisions of Scction 3700 of lhe Labor Code. I shrll. lorthwith comply with thorc provisions.. <br />WARNING: Failurc lo secure workcrs'compcnsation coverilgc is unlawful. and shull suhjcct an cnrploycr lo criminrl Jrcnallics and <br />civil fines up b onc hundrcd lhousand dolles ($lm.m0).additim k, thc cosl of compensation. damges as provided for thc <br />Scction 1076 ofthe Labor inlcrcsl and tccs. <br />l4 <br />I hcrcby altirm undcr pcnalty ofpcrjury that I r,lr under provision ofChapler 9 (commencing with Section 7000) ofDivision 3 <br />of the Busincss and Professions Code. md my liccnsc is in full fbrce md clfcct. <br />Liccnsc L56 *oq e ,+g <br />t\!-1 <br />CONSTRUCTION LFNDING AGENCY <br />I hcrcby aflirm undcr pcnahy ol pcrjury that lhcrc is a conslruction lcndinS rgcDcy tbr thc pcrfttrnrxncc of thc work lbr which this pcrmit is <br />issucd (Scc. 1097. Civ. C.). <br />[,cnder's Nilnrc: <br />hndcr's Addrcss: <br />APPLICANT DECLARATION <br />I hcrchy rllirilr undcr pctrdlty ol periury onc of thc lblkrwing dcclarltions: <br />Dcnlolilion Pcrmits Asbcslos Notification Fcdcrnl Rcgulatioils (Titlc 40. I,r(6) <br />_Requircd Lcllcr of Nolillcation <br />_l ccrlify lhal lhc fcdcral rcgulations rcgtrding asbcslos rcmoval dc not applicable lo this prcj&t. <br />-l <br />certify lhat I have rcad this application and state thal lhc atDvc informtrtion is corect. I agrce to comply wilh all City and County <br />ordiftnccs and Stalc Laws rclatirg to building nuth()rizc ofthis City and Counlylo enlcr upon thc <br />abovc rrcntioncd propcrty for <br />Applirant or Agcnl <br />I'emrilee nanre <br />and <br />fi. <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />I nterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Pipino <br />Gas Pipino <br />Boof 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 l <br />F!NAL L[gl,?/2 Di.(\(Y,r1/+ A'-/ <br />Noles, RemarKs, Etc.-T <br />tzlt?h"r - cl(L b+nrtoz-t +&7 <br />t <br />o,,"c J!/22/fI