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PLUMBING.INSPEGTOR RECORD APPROVALS DATE rD/srG.COMMENTS Owner-Buildcr Dccluation I hcreby affim undcr pcnalry of pcrj ury that I m cxcmpt fm thc Conracton' Licensc Law for thc following rcoon (scc 703 I 5 Busincss md Profcsion or County which rcquirca a pcmit to construct, altq,improvc, dcmolish or repair my structurc, prior to itr or shc is liccnscd puruut to thc provilions ofthcisguuc, also Contactor's thc for such pcmit to filc a signcd shtcmat $d hc Law (Chspa 9, Comocing with Srction 7000 of Division 3 of thc Busincss md Profcssions Codc) or that hc or thc bais fo thc allcgcd cxmption .Any violation of Secdon 7031 5 by ay applicut fo a pemit subjccs thcshc is ud a civil pcnalty ofnot moc thu fivc hundrcd doll6 (S500). c owncr of thc popcrty, or my mploye with wage 6 0lcir solc composation, will do thc work md thc structuc is not irtmdcd or offacd fc ralc ( Scc.7044, Bwitrcss ed Prcfcssiotr Codc: Thc Cof,trrctor's Licruc Law dq not apply to m omcr of thc propcrty who builds or improve thm, ud who dq guch wok hiruclf or hmclf u through his o hq om cmploycs, povidcd that such improvmmB uâ‚¬ not inrmded or offscd fo salc. If, howcva, thc building or improvmmt is sold within onc yca of complction, thc Ownq-Buildo will havc $c budo ofprcving that hc or shc not build or improvc for thc purpmc ofsalc) _I, r oma of thc property, m cxcluively cmrding with licmscd conrrcbm to consmct thc prcjcct ( Scc ?044, Bwinas od Profcssion Codc: Thc Contractor's Licolc Law contrrcts |or such projcctl with 8 Contrrcro(s) I docs not apply to m ownr of propcrty who builds or improvcs thcrcon , od who rLaw)licmsed pumuut to thc Conrrctor's -I, Dstc: &P, I hrcby undq ofpcrjury onc _I havc ud vill minuin a Ccttificatc of Coruat to Sclf-lnrw for wckm' compmratio, u providcd fo by Scction 3700 of thc Labor Codc, for the pcrfmcc of thc work for which the pmit is issucd. _I havc md will maintain wckm' comlmsation insuucc, u rcquircd by Scction 3700 of rhc Labor Codc, for rhc pcafommcc of thc work fu which this pqflit is isucd. lv!y,ror*m' cmpcnsatim insumce cmia ud ;nlicy nmber ecl Poliry Nmbtr .,/ Expirs: _ tmirr*9 00) sl*) that in $c pcf{mcc of thc work for which this pcmit of Califmiq ad is issucd, I shall not in uy munc so c to laws that if I thc workers' Labor Codc. I provisions. Failuc to compcnsation sd shrll subjcct il mploycr to ciminal pcnaltics ud civil fincs up to otrc hundrcd ($100,000),in addition to thc cost ofcompcnsation, dmagcs I providcd for rhc Scdion 3076 of thc Labor Codc, inrscst md anomcy's fccs LICENSED CONTRACTOFS DECLARATION I hcrcby aflim undcr psalty of pcrjury th6t I m licoscd undcr provision of Chaptcr 9 (commcncing with Scction 7000) of Division 3 of thc Bwincss md Profcssions Codc, md my liccnsc is in full forcc ud cffcct. Licmsc Cl6s:_ Liccnsc Numbcr Datc: Cont etor: CONSTRUCTION LENDING AGENCY I heby affim unda pcnslty of psjury thst thm is a construdion lading agmcy fq thc tErfomecc of rhc work for which rhis pcmir is issucd (Scc. 309?, Civ, C.). Lends's Nmcr Lmdcr's Addrcssl Dcmolition APPLICANT'S DECLARATION Notification Fcdcral RcgulatioN (Titlc 40, Part 6) _ Rcquircd ofNotification _t thc fcdcral rcgulations rcSdding abcatos rcmoval uc not applicablc to this projcct that I havc rcad this application statc that thc abovc infomation is corcct. I agrcc to ordinuca md abovc Laws to md hocby authorizc rcprcscnativc with City md County thc UNDER GROUND Waste & Vent Water-Underfloor Gas-Underfloor Building Sewer Area/Storm Drain I nterceptor/ Clarifier TOP OUT Waste & Vent Water Piping Gas Pipeing Roof Drain Tub/Shower Test Rough Water Heater POOL/SPA P{rap/Drain Line Main Drain/Pool Piping Fill Line/Back Flow Pool Heater/Gas Line Misc Gas Service Water Service Lawn Sprinkler ^oSanitary Sewer/Cap ny't A,U Back Flow Device N frIT 4r ,a-1 (L rA,az Rough Plumbing I/^N w Final Gas Test V I l - -'- ,'L Meter Release \,-^J' ,{1" -zY.'11 F!NAL - Notes, Remarks, Etc. I I