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PLUM BING.INSPECTOH RECORD <br />APPROVALS DATE !D/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hereby affirm under penalty of perjury that I m exempt frcm thc Contractors' License ljw for the following rcarcn (Sec.7031.5 <br />Busincss and Profcssion Code)r Any City or County which rcquires a Jrcrmit to conslruct, alter. improvc, demolish or repair any <br />structure, prior to its issuance, also requires the applicBnt for such pcrmit to file a signed slatement lhat he or she is licensed pursuml <br />to thc provisions of thc Contractor's Licensed Law (Chaptcr 9. Commcncing with Section 7000 of Division 3 of lhe Business and <br />PmfcssionsCodc)orthatheorsheisexemptthqefromandthebasisforthenllegcdexemption. Anyviolslionofsection?03l.5byany <br />applicunt for a pennil subjects the applicanl to a civil pcnslty of not morc than five hundrcd dollars (9500). <br />-1. <br />as owncr of lhc propcny. or my cmployees wilh wagcs as their solc compcnsation. will do thc work Md ttE slructm is not <br />intcndcd oroffcredforslc(Scc.7{X4.BusincssandhofcssionsCode:ThcContraclor'sLiccnscLawdocsnotapplytoanowncrof <br />thcprcfrcrly whobuildsorimprevcsthcrsn.andwhodocssuchworkhimsclforhcrselforthroughhisorhcrownemployecs. <br />providcd that such improvcmnts m not intcnded or offercd for sle. If. however. lhe building or irfrrorercnt is sold within one ycar <br />ofcomplclion. the Owncr Builder will have thc burden ofproving thd he or she did not build or impmve thc profErty for lhc purlnsc of <br />elc). <br />-1. <br />as owner of thc pmperly. am exclusively contracting with licenscd conlracloF to construct the prejcct (Sec. 7044, Busincss <br />and PmfssbnCodc:ThcConlraclor'sLicenseLawdocsnotapplytoanowncrofpropcrtywhobuildsorimprovcslhercon. <br />and who contracts for such prejccts with s Contmctor(s) licensed pursuant to the Conlractor's License [aw). <br />I arn cxcnrnt undcr Scction . D. & P.C. for lhis rcason. <br />Date:_ <br />WORKERS' COMPENSATION <br />DECLANATION <br />I hercby affirm u ndcr penalty of perjury onc of thc folbwing dcclaralions: <br />-l <br />havcar[lwill nrainlailaCe(ificaleofConscntloSclf-lnsurcforworkcrs'conrpcnsatknr.as providcdfi)rbyScclion3T00ofthc <br />l-abor Codc. tirr thc pcrlormrncc oflhc work for which thc pcrnlit is issucd. <br />t!!havcanciwillnrainloilworkcrs compcnsxtioninsurancc.as rcquircdhyScction3T(X)oflhcLahorC:odc.tbrlhcfcrl-ornranccof <br />the work li)r which this pcrmil is issued. My workers coilrpcnsnlion insurancc canicr and lmlicy nuillhcr $c: <br />('u.i"r,'rtse,tc Co.-ot-<*!rsvt, \rt<. G. ^.\ <br /><PoricyNumbcr: q? oB y35 * I n Expires:3 I zl zazo <br />h9t ccrrify rlat in thc performance ol thc work for which this permit is issued. I shall not cnlploy any pcrson in any munncr <br />so as to bccorc subjcct lo thc workers'conpcnsrtion laws ofcalitbrnia, and agrcc that ifl should become subject to the <br />workers'compcnsationprovisionsofSection3T00ofthcLatprCode,lshall.fbrthwilhcomplywithtlnkprovisions.. <br />WARNING: Failure k, rccurc workers'conlpensotion covcrage is unlawful. arrd shall subjcct an cnrploycr to criminal pcnalties and <br />civil fincs up lo onc huDdred lhousand dolhrs ($100.000). in addition to thc cost ofcompensation. daroges as provided for the <br />Section 3076 of thc Lali)r Codc. iDlcrcst and 0lbrncv's fecs. <br />r)l lhc lJusirc\s an(l Prrrltrsions Crxlc. anrl rny liccrsc is in Iull li,rcc rDd cllccl <br />(r,""n,"Nu.t", l O 1€ oo 3 <br />(o"t.,\l url'L"l' conrracror: f', 14 gzn''to lih'uva <br />CONS'II{UC'I'ION I,ENDINC ACtrNCY <br />I hcrchy rtllrm undcr pcnally ol pcrjury lhrl thcrc is a constnlction lcndirg rgcncy frrr the pcrfornlrincc of thc w()rk for which this perrlit is <br />issucd (Sec. .1097. Civ. C.). <br />lcndcr's Nrnr: <br />kndcr's Addrcss: <br />APPLICAN'I' DIICT,ARA'IlON <br />I lrrchy alliur uutlcr pcnrlty of pc{ury o[c (,f lhc li)lk)wing dcchrntk)ns: <br />Dcnnrlition Pcrnrjt\'Asbcsk)s Nrilillcrtion Fedcrrl llcgulalioils ('l-illc 40. Parl6) <br />-Rcquir <br />cd l-cltcr of Nolillcation <br />_l ccrlily that llt ltdcrnl rcgulaliurs rcgardiDg flsh(stos rcnr)vitl arc not npplicnhlc k) lhis prcjcct. <br />(11 ccrlily lhill I havc rcad this applicirlk)n aDd slalc lhrt thc atnvc inlbmulio0 is comcct. I ngrcc kr crnrply with rll City xnd County <br />above rcnthned propcny for inspeclion <br />I appticanr or ,lgent <br />l1'r"'iloo nxnro <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 />Ap+ OkP zlrcltotu W4lxe *r <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Piping <br />Roof Drain <br />TubiShower 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 />Rough Plumbing <br />Final Gas Test <br />Meter Release <br />FINAL ?l plZotu lMz*u sg <br />Notes, Remarks, Etc. <br />x <br />/u*", l4i-q12<,zo <br />D,t", \lLq lzazo