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PLUMBING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hocby aftrm und6 pcnalty of psjury that I m crmp fiom thc Cootracto6' Licre l-aw for thc following r@n (Sc.7031.5 <br />B$in6s 8nd Profxion Codc): Any City or County which rcquirG 8 pqrdt to construct, 8ltq, improvg &rnolish or repah my <br />structuc. prior to its isuecc. also rcquir6 thc eplicet for such pcrrnil to filc a signcd statmmt thsr hc or shc b licccd puBut <br />to thc FovisioB of thc Contmtor's Licmscd kw (Chsptq 9, Cormmcing with Sstion 7000 of Division 3 of thc Buins and <br />Prcfc$ionsCodc)orthathcorshciscxcmptlhacfromudthcbosisforthcallcgcdcxmptioo. AnyviolationofScctionT03l.5byany <br />applicmt for s pcdnit subj(ts thc applicut to I civil pcnalty ofoot morc the fivc hun&ed dollas ($500). <br />-1. <br />o omq of thc propcriy, or my cmployc with wage r thcir rclc compwtion. will do the work and thc stnrtrc is not <br />intadcd or offscd for elc (Se.7044, Busine ud Profsions Code Thc Conraclor's Licffi Law do6 not @ply to m oms of <br />thc property who tuilds or improvG thron, md who doe such wrk himsclf or heclf or thrcugh his or ho om mployec. <br />providcd that such imprcvaMts rc not htqded or offqcd for slc. I f, howryq. thc building or imprcvmmt is rcld within one yw <br />ofcomplaion, thc orrn6 Buildq will havc thc hrdm ofproving tha he or she did not build or improvc 0re prcpcty for the purpos of <br />ulc). <br />_1. c omo of thc prcpgty. an cxclusively contracting with licrued contracloN to construct thc project (Se. 7044, Buine <br />ad PrpfusionCodc:ThcContractor'sLiccnscLawdo6notapplytomownoofpropcrtywhobuildsorimprovcsthseon. <br />md who contncts for such projets whh a Cortraclo(s) licsed purs@t to the Contractor's Lic@e tsw), <br />-l <br />m exempt unds Swtkrn--. B. & P.C. for this re6on. <br />YABrc$5Q!!8ENIAIIAN <br />DECLAITATION <br />t hccby affm undo poraltyof pojuryonc of the following delsatiom: <br />-l <br />havc srd will roint8in a Cqrificatc of Comt to SclfJmuc for workm' composaion, c povidcd for by Sction 3700 of thc <br />I-abor Code for thc pqfommcc of thc work for which thc pqrnit b issucd. <br />-l <br />havc and will maintain works' compc$ation iNurancc, 6 rcquircd by Sation 3700 of thc Labor Codc. for thc pqfommcc of <br />thc work for which this pcrmit is issucd- My work6' compostion iuurmcc miq ud policy numbo ac: <br />Policy l-\-tv <br />_l certiry that in thc pctfomcc of the work for which this prmit is isucd. I shall not oploy uy pason in ey mmn6 <br />rc s to bqorc subjet to thc wrt6' compqEalion lam of Califomia, od agc that if I should b6omc subjct to thc <br />work6' @mpqstion pmvisiore of Scrion 3700 of thc Lsbq Codc. I shall. fonhwith comply with thos prcvisiou.. <br />WARNING: Failure to suc worlm'compqualion covmgc is unlawful, md shall subjet o mpbyc to qiminal pqultie ed <br />civil fine up to onc hundrcd thosnd dollm ($100.000). in addition to thc cosl of compcwtion. darugo re provided for the <br />Setion 3076 of thc labor Codc. intaGt md dtomey's fc. <br />D",", G)-L1-fl C <br />I hrcby affrm undo poalty of pojury that I m licoscd 9 (comachg with Scrion 7000) of Division 3 <br />of thc Bwinq md PrcfBioN Codc. ed my licre is in full forcc ud cffst. <br />r-i"*"ct"*' B t-t*tb t- <br />o'r'' (4-1i\-('\ <br />CONSTRUCTION LENDTNG AGENCY <br />I hwby affm undo pcnalty of pojury thd thqc is a congruaion hnding ag6cy for thc pqfomcc of thc work for which thb pgrnit b <br />isucd (Sc. 3097. Civ. C.). <br />l4ndq's Nmc: <br />I crrttr s \,iiIeis <br />ASSJCANLDECI.AEABqN <br />I harty atrrru unda pcnalty of pcjury onc ofthc followirg dclaraions: <br />Dctrolitioo PmiteAsb6tos Notification Fcdqal RegulstioB (Titlc 40, Ptrt6) <br />-Rcquircd <br />lrtt6 of Notificdion <br />_l cctiry that thc fuoal rcgulatioru rcleding ubctos rmoval rc nol spplicablc to this projet. <br />-t <br />cdiry thst I havc ud this applicarion ed statcthal thc abovc infomtion is corect. I agrG to comply with atl City ild Couty <br />ordinmca md Slatc hws rclating to building connrudioq ud hdcby suthoriz rcpr6@tativ6 of this City ud County to mtq upon thc <br />abovc motioncd propcrty for insp€ction <br />Permlte nlme (print): <br />o",", (o-11-..r <br />UNDER GROUND <br />Waste & Vent '//9t I l/,,, <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />I nterceptor/ Clarifier <br />TOP OUT I i <br />Waste & Vent t+\ <br />Water Pipinq <br />Gas Piping v /V <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 />/I I <br />Rouqh Plumbinq rut I <br />Final Gas Test * <br />Meter Release rl .tl I rl <br />F!NAL t_iltllA,+:flf-.-Ir INotes, Remarks, Etc <br />/,H <br />>frfl,vl <br />Appllcrnt or ASent Slgnalure:{ <br />lt l'l /N\ <br />Itt t'1 u /