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PLUMBING-!NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS 0WNI.:R BI III,l'F,R I)EI.('ARATIoN <br />I hcrchy alfirnr untlcr pcnrlty ol pcr.;ury thrt I urr crcnrpt l'ronl thc Contr:rct{)r\' Liccn\c Law f('r thc li'lkrwing rcasoil r8..7lt.l1.5 <br />Busincss and Profcssion Codc): Any Cily or County which rcquircs a prnril to construct. altcr. iillprovc. dcmolish or rcpair any <br />slruclurc.priort)ils isslrncc.alsorcquircslhcapplicanllorsuchpcrlritk)filcnsigncdslalcftDt lhalhcorshcisliccnscd pursuanl <br />to lhc nmvisions of lhc Conlrnclor's Liccnscd Lrw (Chrptcr 9. ConrnEncing u,ith Scrli([ 70U) of Division ] of thc Busircsr and <br />ProltssionsCode)orlhalhcorshcisexcnlptlhcrcliomandthcbusisfotthcallcgcdcxemplion. AnyfiolationofScctionT0-3l.5byany <br />applicantforafcrmilsuhjcclslhc applicanlloacivilpcnaltyofnotnx)rclhanllvchundrcddolldrs(S5U)). <br />-1. <br />ils owncr ()l'l hc pfi)Nrly. ()r nry crnp l(,yccs w il h wil8cs ils t hcir solc cortpcnsat trn. will do thc work ancl tlE slructurc is n(il <br />lhc pmpcny who huikh ()r inprolcs llErcul. ilnd wh() (l(rcs rlch rvork hirnscll or hcrsoll or through his or hcr own crrployccs. <br />ol conrplclion. Ilr O* ncr tluiklcr t ill havc thc burrlcn ol pror irrg that hr or shc did [(il huikl or itnpro\c rlrc pffrFf], li)r thc purFx)* ot <br />salc I <br />-1. <br />as owrer of lhc prolrcny. am exclusively conhacling wilh liccnrcd conlrlcbF to conslruct thc Imject (Sc. 7O44. Busircss <br />attd Prnfcssion Codc: The Conlraclor's Licensc Law docs nol apply to an owncr of propcny who builds or improves thcreon. <br />{nd who conlracls for such troj€ts wilh tr ConlEcb(s) licenscd pursuant lo lhe Contractor's Liccnsc [rw). <br />-lamexcmptundcrscclil)n-.B.&P.C.forlhisrcason'Dste:_Ornen_ <br />WORKERS' COMPENSATTON <br />DECIIEAIIQN <br />I hcrcby afnrm undcr Fnally of fErjury onc ofthc following decluations: <br />I -nh(,r Codc. lbr thc pcrli)irhncc of lhc work li)r which thc pcilnil is is\uc(!. <br />_l havc and 3700 of the [rbo, Codc. for the psfomncc of <br />lhc work fot ud grlicy numbcr uc: <br />llxnircs:Policy Numhcr: ./ <br />^!crlily <br />lhill ilr Ihc |crl'nrHrcc (,f thc work l'(n s'hi(h this pcrnril is isrucd. I rhall n(il crtlpk)y rny l)cl\oi in any mltlncr <br />so artohccorrrcsuhicettorhcworkcrs'cotrrpcilsnlionhw\ol('alilbrnix.artrlrgrccthrtiflsh()uklbcc(Jntsuhicclk)lhc <br />workcr\'conlpcilsalioip()\'i\ionsoiScclion.17(X)ollhcLahrrCrxlc.Ishrll.lirihuithcoitplywiththoscprovirions.. <br />WARNING: Failure lo surc workes'@mlEnsalion covcmgc is unlawful. and shall subjel an cmploycr to aiminal puhics and <br />civil fines ul to oE hundred thousnd dollm ($l in addilion to thc cost of compensalion. darmges as providcd for thc <br />Scction 307( of'l-thc lntDr Codc. inlercsl andq <br />I hcrcby affrm undcr pcnalty of fErjury that I am liccn*d ol Chuplcr 9 (Sccli(n 7(XX)) ol Dirishn l <br />of thc Business and Prcfcssions Code. and my licenre is in full fore afld effcct. <br />rc-JLiccnsc <br />C()NS'I'RI'C'IION LI:NDINC /TCI.'NCY <br />I hcrchy aflirm lndcr frnally of perjury lhal lherc is a construclion lcnding sgcncy lbr lhc Jrrformncc of thc work for which lhis ltnnit is <br />issucd (Scc. -3097. Civ. C.). <br />lxndcr's Nam: <br />kndcr's Addrcss: <br />APPLICANT DBCLARAl'ION <br />I hnhy aflirm undcr pcnrlty ol pcrjury onc ()f thc li)lk)wing dcclxral ions: <br />l)cnxrlition Pcrmits A\hc{tos N(nillcrlion Fcdcrrl RcSuliltions (Titlc rl0. Pnn6) <br />-Rcquircd <br />Lctlcr ol N(rilicrli(,n <br />_l ccnity lhal lhc ftdcral rcgulati(nrs rcgarding n\hcsk)s rctnoval rrc n(x tpplicablc k) this fr+ct. <br />{orif y ,f,n I hrvc rcnd lhis apf lictrtion nnd slrlc lhal lhc ntnvc inlonn{iion is coftcct. I ilgrcc lo conlply wilh 0ll City flnd County <br />ordinanccs and Statc hws rclating to building construction. and hercby aulhorizc rcprcscntatives of this Cily and County to cntcr uFnn thc <br />ilrvc rcnttnrcd propcrly for <br />Applicont or Agent <br />Pemite mme <br />D,1". / -? -ZO <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf loor <br />Buildinq Sewer <br />Area/Storm Drain <br />lnterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Pipino <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rouqh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />[\Iain 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 Plumbinq <br />Final Gas Test <br />Meter Release .r\\r \\r ttl <br />FINAL '1\N\%iu up[]ilvJ JU rb <br />Notes, Remarks, Etc. <br />, <br />/o b oob>