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PLUMBING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNI]R BI III-DI:R DELCARA'TION <br />I herchy aflirrn undcr penalty ol perjury thtt I ailr eicntpl lionr lhe Conlr.clors License Law for the firlkru,ing rea$n (Sec.?0.ll.5 <br />Business and Profession Code): Any City or County $'hich requires a pnnril lo conslrucl. nller. inlprove, denrrlish or nTair any <br />structure.nriorloils issuancc.als()requirestheslplicantlilrsuchJrermiltrlileasigncdslilement thxtheorsheislicenkd pursuant <br />to the provisions oI Ihe Contrrclor's [,icensed Law (('hapter 9. (irn]mencinE with Scclion 7000 of Division -'1 of the Dusiness anrl <br />Prolisstr)ns Code) or thnt he or she is exempt thereliom ard the basis for llrc allegerl exemplion. Any violxlion ofScclion 70-1 I 5 h!'ony <br />applicantforaperiltilsuhjcclsthc applicanttrocivilpenahyofnotnmrelhaillilchun(lrc(ldollars(S500). <br />.l <br />_1, as owrer of thc pmFrty, or my employes with wa8es ai lheir sle comfmmtion, wiltdo lh€ wo* ad lh€ struclw is ml <br />intcndcd orolferedforsle(S$.TM4,BusiressandPmfessionsCode:'lheConttactor'sLicmseLawdocrmtapplytoonownerof <br />thc pmFrty wtn builds or impmvB themG arxi wlb &B mch mrk himself or hcmlf or lhmugh his o. hcr own employee, <br />prcvided rhar sch impmwnts m mt intcrdcd oroIiH for sle. I[, tnwev6, lhc tililding or irpmwmt h sld within orc ]ce <br />of complaioq thc Orvncr Builder will haE tlrc burdo of pmving that he or she did mt build or impmrc the pmpsty for thc purporof <br />ule). <br />_1, as owner of thc pmperty, am exclusivcly conlractinS with liccnsd contmcton lo mn$rud th€ prejccl (Sec. ?(N4, Business <br />ard PmfessirnCode:'[heContractor'sLiccnseLawdocsnotapplylo0nownerofpropertywhobuildBorimpmvdthermn, <br />and who conlmcts for such pmjects with a CoilBclo(s) licensed pursuant to the Conlractor's License Law). <br />-lamcxcmptundcrsstion-'B.&P-C.forthisreasn.D{tel Owner: <br />I hereby affirm undcr penalty of perjury onc o f the following <br />_l haveamlwill nuintainoCeflillcateof(i)nsenltoScll:losurelirrrvorkers'contpensalion,as nmlidcdforbySeclionlT0(loIlhc <br />Lahor (irde, frrr lhe perfomnce of the stlrk for q'hich the pernil is issued <br />lhavelnds,illnraintainworkers'conlpcnsrtioninsurance.ns rcquiredhySeclion3T00oflheLahor(bde,lirrlhenertormnnceoI <br />the s1)rk lilr which lhis permtl is isrued. My rvorkers coorpensatbn insurance carier and Jxrlicy nunrhcr rre: <br />Policy Number: Lxpircs: <br />_l cenify that in the performance of the work lor which this permit is issued, I shall not employ any peNon in any manner <br />so as (o become subject to the workers'conrpensalion laws ofCalifomia, and agree that ifl should become subject to the <br />uo*ers'compenmtionprevisionsofSslion3T00oftheLatnrCqle,lshall,fonhwithconrplywithlhrrpmvisions.. <br />WARNINC: [:6ilurc to wurc workerr'smpcfication covemgc is unlawful, and shall suhjet an mploycr to oiminal pe@hi6 ond <br />civil fincsuptoonchundredthousnddollars($100,000),inaddiliontolhecostofcompensation,damSesasfrovidcdforthe <br />S(tion 3076 ofthc Lshor Codc, intercsl and anomey's fcs. <br />.{ppllcrnt: <br />IJCIN,TED-CONIBACI$A <br />Df,CI.ARATION <br />I hereby ollrm under penalty of perjury lhal I am licened under pr)vision ofChapter 9 (omrnercinS with Sstion 7{}00) ofl)ivision l <br />of the Business ard Pmfessions Code, and my license is in full ft)rce and effect. <br />Liccm Clffi :-Liccroe Numbcr: <br />Contractor: <br />coNs l R[rcTloN LI NDtN(; A(;1'NCY <br />l hen'hy a llirnr rulcr pcnalty o f pcriury thrl lhere is a consl nrcl ion lcilding agency for lhe perli)rmancc o t lhc work fi)r which llris pcrnil is <br />issued (Sec. .1097, ('i\'. C.). <br />Lender'9 Name: <br />Lenrler's Ad<lress: <br />APPLICAN'I' DECLARAIl0N <br />I herhy aflinn under penalty ofperjury one of the following declaratrrns: <br />Dem)lition PerDils-Asheslos Notification l;c(leral llegulalions ('l illc 40, Pnd(,) <br />-Rcqurre<l <br />Leller of Nolilic.lku <br />-l <br />ccniry lhat lhc federal retulationr rcgarding asherkrs removal are nol applicsble to lhis pmjecl. <br />_l ceatify that I havc rcad lhis application and state that thc atnve infomtion is coret. I aerc to comply with all City and County <br />ordinanccs and Statc Law rclating to building constructior\ and hcrcbysuttnrize representativcs ofthis City and Counly to enttr ulnn lhc <br />above mntioned pmpcrty for iftcpcction purtoses. <br />Appllcana or Aprnt <br />Pernriter name (prlnt): <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />I nterceptor/ Cla rifier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rouqh Water Heater <br />POOUSPA <br />P{rap/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 />Rough Plumbing <br />Final Gas Test <br />Meter Release <br />FINAL |-Zy-2!/4t > Jd.t ;@ <br />Notes, Remarks, Etc.