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PLUMBING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS ()WNER DUll,t)tlR Dtll,CARA'IION <br />I hcrchy dllirrr uodcr pcnally of perjury lhul I am cxcnril lil)nr lhc C(!nlrrck)rs l,iccnsc l.aw li)r thc lolhwing rcr\oil (Sec.7oJl.5 <br />IJusircss artd ['r()lcssi(xt Codc): Aoy Cily or C]ounly qhich rcquircs a pcrtrril lo c()nstrucl. ollcr. imfr)vc. dcilxrli\h or rcpair xny <br />slnrclnrc. prior to itr issurncc. also rcquircr Ihc applicxnl lilr \uch frrnlil l() lilc o signcd \txlcrmlt thill lrc or shc is liccnscd purrutnl <br />lo lhc proli\ions ol-llt CoDlracbr's Liccnscd Lrw (Chnplcr q. Connncnci[g rvilh ScclioD 7(XX) of Division ] ol'thc llusiiless a[d <br />trpflicnilllorrpcrnrilstrhjcclslhc ilflicailllorcivilpcnallyol'nolnx)rclhflnl'ivchundrcd(k,llnrs($5(/J). <br />-1. <br />a( owncr of lhc prolEfly. or nly cnlpk,yccs wilh wagcs rs lhcir solc coilrl)cnqnli()n. willd() lhc work arxl thc slrolurc i\ not <br />iilcilql orollircdlirrqlclScc.TOl.l.[]usincsrandProltssionsCodc:'IhcCollractor'sLiccnsclf,rwdocsnotapplyk]0oownerof <br />lhc pn)Itf,y who huilds or iNprelcs lh((r)n, aild who docs such urtrk himsclf()r hcrsclfor through his or hcr o*n cnrployccs. <br />provi(lc(l lhdl slch inrprotutills:m nol inlcndcd orollcre(l lirr sab. ll howclcr. thc btrilding or irnprolcnrcnl is sold withir onc )ear <br />ofcotrflclion. lhe Owncr Iluildcr will hnvc lhc burdcn of proving thrl hc or shc did n(,1 buikl or improvc thc propny I(,r lht purlnse of <br />salc ). <br />1k ". <br />u*n", nt-th"f(rpcr!y. unr cxclusivcly conlraclir1t $ith liccn\cd contrnctrrr\ k) construct th. proFct (Scc. 7(H4. Busincss/antl lhrlirsionCo(tc:_lhcConlractor'sl-iccnscl-xwdoc\notappl)'loailorvncrofpropcrtywhohuildsorinrprovcsthcrcon. <br />and sho contracls li)r such prcjccl( silh a C(nilracl(tr(s) liccn\cd pursuonl k) thc Coolrack)r's l,iccnsc liw). <br />-l <br />am cxempt undcr & P,C.this rcnsoil. <br />Dil".pz-o g- z\ <br />l hcrchy uflirrn undcr lcnally of I--rjury onc of lhc followi0g dcclilrnti(ilrs: <br />-l <br />havc and will nuinlrin n Ccnilicrtc of ConscDl lo Self-lnsurc li)r workcrs' conrpctrsatio[. as f,rovidcd lor by Scction .17(D of the <br />Latxrr Code, l-or thc pcrlbrnrncc ofthc s(trk for rvhich Ihc pruit is issucd. <br />-lhr(candwillilrainlain$orkcrs <br />c()illpcn\nti()ninsurancc.as rcquircdhyScction-37(X)ofthctaborCodc.forthcpciloilmnccof <br />thc rvork lbr which this pcrnlil is issucd. My workcrs cotrrpcnrrti()n insurancc carricr and policy nunrtrr arc: <br />Policy <br />_l ccrtil-\'lhat in thc pcrlirrnuncc ol thc work ti)r \\'hich this pcrmit is issucd. I shrll nol cnrpk)y r0y pcrson itr rty mrnncr <br />so rs l() k+cotrrc subjccl t, lhc sorkcrr'c()nrl)cnsilion hws ol'Calil()rnin. iln(l agrcc thal if l sh([kl hcconrc subjcct k) thc <br />WARNING: Failurc lo rccurc workcrs'@mJrcnslion olrm8c is unlawful. and shall snd <br />civil fincs up to orc hundred thousand dollus ($l in addilion lo lhc cost of lhc <br />Scction .1076 oflhe Labor Codc. inlcrcsl end <br />5 <br />I hc(by aflirm undcr pcnally ofpcrjury lhrt I am liccnwl umlcr pn)vision ol Chilplcr 9 (comlEncing wilh Scclion 7fiX)) of Divisi<lr 3 <br />of lhc Busincss and l'rofcssions Codc, snd my license is in lull tbrcc and cllcct. <br />Liccnsc Class:-l-iccnsc Numhcr: <br />l)ale <br />CONSTRTIC'I'I(IN LENDINC ACI]NCY <br />is\ucd (Scc..1097. Civ. C.). <br />lrndq's N8m: <br />lrndcr's Address: <br />APPLICANT DECLARATI(IN <br />I lwby allimr undcr pcilolt y of pcrjury onc of lhc fbllow ing dcclarnt ions I <br />Dcnx)lition Pcrmils-Ashcshs Nolilication fcderal Rcgulntklns ('l itlc 40. Paa6t <br />_Rcquircd Letlcr of Nolification <br />-l <br />ccnity lhot lhc fcdcralreguhtions rcguding ashcskrs rcm)val arc nol rpplicahlc k) this p()jcct. <br />?-, ccnily thtl I havc rcad this applicali()n iud slxlc lhal lhc !h)vc inlonnatt)n is cotrcct. I alre b comply with all City and County <br />ordinanccs and State [{ws <br />abovc mntioncd propcrly <br />lo building construction. and hercby authoria rclresentatives ofthis City ud County lo cntcr upon thc <br />Apl,li(ilil1 or Agetrl <br />-E-ePcrtrrilce nnnte <br />tt^r"i '/' ( '-- ) ( <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />lnterceptori Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Pipino <br />Roof Drain <br />Tub/Shower Test <br />Rough 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 as ')-v 4 /yw\tyl <br />Notes, Remarks, Etc.I <br />( <br />Dole:-b