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PLUMBING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.gOMMENTS 0wner-Builder l)eclar8lion <br />I hereby affrrm under penalty ofperlury thal I anl exenlpl form lhe Conlrsclors [-rcense liw for the following reason (sec ?0:l l. 5 B.sin6s. <br />and Profession Code): Aily Cily or Counly which requircs a permil lo construct. altcr. improve. denrolish or rcpair any structure. prior to its <br />issuance. also rcquite the applicant for such petmit kl filc 6 signcd slalenrcnl that hc or shc is liccnscd puBuanl to thc prolisiom oithe <br />Contractor's l-icensed Law (Chapler 9. Conrmencing wilh Seclion 7000 of Divisfun 3 of lhe Business and Prof*srons Code) or that hc or <br />shc is exempl thereftom and lhc basis for the sllcgcd excntption .Any violation of Seclion 70.1 L5 by any applicant for I penbit subj.:ts lhc <br />applicant to a ci!il penalty ofnol morc lhan li!c hundrcd dollars ($500). <br />_1, s own6 of lhc prcpcny. or my cmploycG with wag6 as lhcir solc compcnsation. will do thc work snd thc atructuc is not iot.nd.d <br />o, offctcd for $lc ( S*.7044, Busin6r rnd Ptofasions Coder Thc Cootrsclo.'s Licc6c Lrw dos not .pply to an omer of thc prcpcny <br />who buildr or improvB thqcon. and who do6 $uch work himsclfor heBclfor th.ough hir or hcr own employecs. providcd thsl such <br />improvcmcnls arc not inlcndcd or offcrcd for ralc. [f. howevcr. thc building or improvcmcnt is sold within on. ycar ofcomplction. thc <br />Ownq-Buildcr will hrvc thc burdcn of proving thst hc or shc not build or imp.ovc for thc purposc ofsalc). <br />_1, I ownq of thc propcny. am crclusivcly conlracling with liccGcd cont6ctoG to coNtrucr thc projcct ( Str. 7044. B6io6s and <br />Profcssion Code: Thc Contttdot's Liccnse llw do6 not apply to .n oM.r ofpropdty who builds or inrprove th.ron , 6nd who <br />contracts for such proj*ts with a Contractor(s) liceNad pursusnt to lhc Contracto.'! Lic.nsc law ) <br />_l am cxcmpt undcr Scction _____.8. & P.C. for lhis rcason <br />Datc:()uncr: <br />WORKERS COMPENSATION DECLARATION <br />I hc.cby aflirm undfi pcnally ofpcrjury onc ofthc following d(laratios: <br />_.1 have and u ill mainlain I Ccrtificalc ofConscnl to Scl[-lnsure for workers compensation. as provided for by Section 3700 ofthe <br />l-atx)r ('odc. for the perforrnance ofthc work for which lhe pennit is issued. <br />_l have and will rointsin workers' @mpenslion insunnce, as rcquircd by Section 3700 of thc trbo, codq for Ihc performncc of thc <br />work for which this p€rmit is isued. My workos' ompcnstion irsumce canio and policy numbcr uc: <br />( rrrrcr <br />Policy Numbcr:__Ii\pircs <br />(This scclion nccd nol bc conrplcled iflh. pcrmil is for (he hundred dollsB l$1001 or less) <br />_ I cenify that in (hc performancc oflhc work for which this pcrmit is issuld. I sh&ll not cmploy any pcmon in any manncr so as to <br />bec8me subJEl to lhe workers ' compenution hws ofCalilornia, and sgre that rf I should beconre subj(t to the workers' <br />('rxlc. I forlhw thosc <br />coverage is unlawful. and shall to qiminal penaltics and civil <br />fm6 up to onc hutr&cd thoMd dollm ($100.000).in ddition to the cosr of <br />thc Lsbor Cod., intcrBl and attorncy's f6 <br />damagcs r providcd for thc Setion 3076 of <br />LICENSED CONTRACTORS DECI.ARATION <br />I hscby aflim undcr pcnalty ofpetjury thst I m liccnscd undcr provilion ofchsptcr 9 (commcncing with Scction 7000) of Division 3 of <br />thc Businc$ and Prof6sio6 Codc. and my liccroc is in full forcc md cffcct.?8//Liccnse Nunrbcr 6 6 <br />.Contrsclor: <br />I hrcby aflirm undtr pcnalty of pcrjury thsi thcrc is a coNtructiotr lcnding agcncy for thc p€rfomrncc of thc work for which this pcmit is <br />issued (Sec. 1097. ('iv. C.). <br />Lender's N!mcr <br />Lender's Address <br />APPLICANT'S DECLARATION <br />Dcmolition Pmits-Asbcstos Notification Fcddsl R.gul6tions (Titlc 40. Pan 6) <br />_ Rcquircd t ttcrofNotification <br />_l ccnify that thc f€dcralrcgulations rcgarding sbestos removal ilc not applicablc to this projcct. <br />_ I cc(iry that I hsvc red this applicEtion and statc that thc sbove infomation is concct. I agrcc to comply with all City and County <br />ordinancB snd Statc lrws rclating to building coNtruction. ud sulhorizc rcprGcntalives ofthis Ciry and <br />abovc mentioned propcrty for inspection <br />ApplicEtrt or agcnt sig.: <br />Pcrmittcc namc (print): <br />Dalc:p 0 <br />lo upon lhc <br />UNDER GROUND l) llt,//L -rbWaste & Vent 4'l b///.Ubq,@) <br />Water-Underfloor <br />Gas-Underfloor <br />Building Sewer <br />Area/Storm Drain <br />I nterceptor/ Clarifier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Piping <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 />Misc <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewer/Cap <br />Back Flow Device <br />Rough Plumbing <br />Final Gas Test t <br />Meter Release Jl nl th 'frS/(0//t41 . <br />I <br />FINAL <br />Notes, Remarks, Etc. <br />Datc: <br />WARNIN(; <br />Dale: