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PLUMBING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OlvNER BUn.t)ER l)8:L('ARA'l'loN <br />I hcrchy allirrn undcr pcnillty ol pcrjury thrt I anl cxctlf lionl thc Coilrrctor\' Licc[sc' l-xw l'()r thc followiig rcr{on (Scc70.11 5 <br />llusincss ilrxl Prolbssirn (irdc): Any City or County $hich rcquirc\ a Frnlil lo con\lrucl. altcr. inrprovc. dcmolish or rcpiir ilily <br />\tructurc. pri(tr k) ils issurncc. also rc<luircs thc applicnnl for \uch lttiil lo lilc a sigicd slnlctrnl lhxt hc or shc is liccnscd pursurit <br />k) thc provisions ol thc Coillrxclor's l-icctrscd Law (Chapler 9. (\rtrrncncing with Scction 7(Xx) of Division .1 ol thc Bn\incss rnd <br />al)plicrtrlli)rrpcrnrilsilhjcct\lhc ilnplicanlhrcivilpcnilllyoftroltrx)rcthrlllvchun(lrcd(lollrrs($500). <br />-1. <br />as owrer of the fropcrty. or my cmplolees with wages Bs tlreir sle compensation. will do the work ud the slutw is rel <br />inlcrdcd oroffsed for sh (Sc.7(X4, Busiress and Profcsshns Codc: The Contractor's Licens hw does not spply lo an owner of <br />tlEfmperty whohuiktroritrprosthemn.urdwhodmshm*himselforhcrslforlhmughhisorherosnemployees. <br />providcd thst such imprcwrils e mt interded or offered for sh. lf. howew. the boiHing or ir{,mrcrcnt is rcld sithin orc }etr <br />of corpletion. tlr Owrer Buiklo will hrw tlE burdcn of Foving that hc or she dil ret buiu or irprevc 0E pmperty for thc purJns of <br />uh). <br />_1. us owner ofthe prcpefly. am exclusively contracting with liccnscd conlraclors to conslruct lhc prejcct (Sec. 7044. Busincss <br />and Prcfcssbn Codc: Thc Contractor's Liccnse Lsw does not apply lo an owner ofpropcrly who builds or improves thercon. <br />and who conlracls for such preFcls wilh a Conlrtrclo(s) liccnscd pursuant to the Contracbr's Liccnse Law). <br />-l <br />am cxcmpl under B. & P.C. for this reason. <br />WORKFRS' CoIIIPENSATION <br />DECI ARATION <br />I hcrchy aflirm under penalty of pcrjury onc of lhc following dalarutions: <br />l.rh(n-(ixlc.lorlhcpcrli)rntilnccollhcworklorwhichlhcpcrilril i\is\lrc(l. <br />_l have and will mainl0in workcrs' compcosation insurancc. as rcquircd by l <br />thc work for which this pcrmit is iss€d. My worktrs' conr[rcnsation insurarcc <br />Setion3700ofthct bor <br />cmier ed lblicy numhcrFr-^a-s\ <br />Codc. for lhc pcrfornuncc of <br />ore: <br />a \I z\Policy <br />_l ccmify lhat in thc pcrformancc of thc work for which this pcrmit is issucd. I shall not cmploy any pcrson in any manncr <br />so as lo hccom subjcct lo I hc workers' compcnsation laws r:f Calilornia, and agrcc lhrl if I should hccorc subjcct to lhc <br />workcrs' compcnsation provisions ofScction 3700 ofthc Latnr G)dc. I shrll. fofthwilh comply with thore provisions.. <br />WARNING: Failurc to scurc workcrs'compensalion covcmgc is unlawful. and shall suhjccl an cmploycr lo ffiminal Fmltics and <br />civil frncs up lo onc hundrcd thousand dollrs ($100.fix)). in addilion to of compensation. damges as providcd for thc <br />Sstion 3076 thc labor Codc. irletcsl and altomy's fccs. <br />,b u t <br />()l thc Ilu\incss xn(l llrrlcssiorrs (ixlc. antl nry liccnrc ir in l'ull lirrcc rn(l cllcct.l'il ' <br />0-s tLiccnsc Numbcr: r r6s+3 4 <br />e <br />CONS'TRUCTION I FNDINC AGENCY <br />I hcrchy s[firil undcr frnalty of pcrjury thal thcre is a constructirn hnding agc[cy for lhc pcrti)rmencc ofthc work for q'hich this lErrnit is <br />issucd (Scc. 3097. Civ. C.). <br />[rntlcr'r Narrc: <br />hodcr's Addrcss: <br />APPT,ICANT I)T]CI ARATION <br />I lm$y alnni undcr Nnrlty of pcrjury onc of thc lirllouing tlcclarrthns: <br />[)rrnoliti(rn Pcrilrits-A\hcstos Notiticrtion Fcdcral Rcgulali(xrs ('I itlc {0. Parl6) <br />-Rcquircd <br />t{ltcr of Nolificntion <br />| <br />-l <br />.crtity thilt thc lbdcrll rcgulrttrrs rc8ilrding ashcsk)s rcrmrvrl rrc nol applicablc lo lhis proiocl.t- <br />lE ."nify rl"r I havc rcJ(l thi{ ilpplicxlion and sttrtc lhrt lhc atx)vc inli)rnrxlion is conccl. I ngrcc to cr)trrply wilh all City aril County <br />above mnlioncd pmperty for <br />Applicant or Agenl .t <br />Pemlte name (prinl):( <br />zo <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 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 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 Plumbing <br />Final Gas Test <br />Meter Release <br />FINAL 94-7fi hr.i -i(l ?ru1irk+ Ufrfla- r.rrrrtfroc <br />Notes, Remarks, Etc. <br />9<arsr! fo) t-?A-2n <br />--D <br />l)illr ()silrr <br />csniar. t \nasurar.ce Cot\tutv^ # Ih.a <br />Dale: <br />Confrsctor:( <br />/