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PLUMBING.!NSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hscby aflim undo pcmlty of pcrjury that I m qmpt from thc Contractots' Liccre lrw for thc following r@n (Se.70-11.5 <br />Buin6s and Profsion Code): Any City or County which requirc a pcrnit to construct, altc. imprcE, danolish or npeir uy <br />struclurq Fior to its isuuce. also requiE thc applicut for such pcnnit to filc I sigtrd statmmt that hc or 8h€ b licosd puGuant <br />to the provisiore of thc Contrctor's Licmscd Law (Chapt6 9. Commcncing with Setion 7000 of Division 3 of thc Buine and <br />Prefeions Codc) or thst hc or shc is cxcmpt th@from ild the basis for thc allcgcd amption. Any violatioo of scrbtr 70-11.5 by any <br />rpplicsntforapcmitsubjtrEthc applicanttoacivilpcnaltyofnotmorethmfivchundrc{dollus(5500). <br />_1. as owner of the propcrty. or my employec with rvages as their sole compeflsation. will do the worft and the gructure is not <br />intendcd or offered for sale (Sec.7014. Business and hofessions Code: The Contractor's License Law does not ryply to an orvner of <br />the property who builds or improves thcron. and who does such rvork himself or hcrself or through his or her own employecs. <br />provided that such improvanents are not intendod or offered for sale. |f,, horvsver. the building or impnovcmcnt is sold within one )car <br />of complaiorL the Or*ner Builder rvill have the burden of proling thd hc or she did not build or irnpmove the property for the purposcof <br />sale). <br />-1. <br />as olner of the prop€ay. am exclusively contracting rvith licensed contractors to construct the projecl (Sec. 7044. Business <br />and Pof€ssion Code: The Contractor's License Law does not apply lo im o\l'ner of propenty s'ho builds or improves lhereon. <br />and rvho contracts for such projects rvith a Contracto(s) licarsed pursuant to the Contrac{or's License Law). <br />-l <br />am exempt under Section-. B. & P.C. for this reason. <br />l)alc:( )rr ltcr:%iffi <br />I hacby affim undo pcnalty of pajury onc ofthc follorving dclaations: <br />-l <br />hsvc drd sill maintain a Cqrificatc of Conmt to SclfJnsurc for wortm' compostion. c previdcd for by S(tion 3700 of the <br />Labor Coda for the pcfomcc of thc uo* for uhich lhc fmit ir i$ucd. <br />,Z(haveandwillmaintainworkm'comperuationinsunncc.a rcquircdbySction3TO0ofthcLaborCodc.forthcpcfomance oft <br />::- <br />t"lt'ht#}li iscd Mv workm' omposation irourucc cmir md poricv numbc rc: <br />Poricy.,,*, fhbzY 60 I 3a l1 rxpiri: 'l - Ol - Zo'lg <br />-l <br />certi$ that in the performance of the rvork for which this permit is issued. I shall not employ any person in any'manner <br />so as to become subject to the rvorkers'compensation larvs of Califcrrnia. and agree that if I should become subject to the , <br />workers' compensation provisions of Section 3700 of the Labor Code. I shall. forthrvith comply with thosc provisions.. <br />WARNING: Failure to secure rvorkers' compensation coverage is unlau'ful. and shall subject an anployer to cr3ltinal poralties and <br />civil fines up to one hundred thousand dollars ($100.0001. in addition to the cost of compensation. damages as provided for the <br />Section 3076 of the Labor Code. interesl and <br />f )oln.2:%'b?pt <br />DECLARATION <br />I heretry affrrm under penalty of perjury that I am licensed under provision of Chapter 9 (commencing rvith Section 7000) of Division 3 <br />of the Business and Professions Code. and my license is in full force and effect. <br />- <br />License ct^*, C3 b <br />Dere: <br />tZ,-ZFZoZo <br />W <br />I hccby allirrn undr penslty of ptrjury that thqc is a renstruclion lqding agmcy for the Jnfomacc of lhe rvork for Nhich lhis perrnil is <br />issucd (Ss. 3097. Civ. C.). <br />knder's Name: <br />Lender's Ad&ess: <br />APPLI('ANT DT:('LARAI'ION <br />I ho'etry affinn under penalty of perjury one of the follos'ing <leclarations: <br />Denrolition Perrnits-Ast:eslos Notification Federal Regulations ('l'itle 40. Part6) <br />Rcquired l.ctter of Notilication <br />-l <br />ceni& that the federalregulations regarding asbestos reinoval are not applicable to this projed. <br />4ifytharthavereadthisapplicationandstatethattheaboveinformaionis with all City and County <br />and County to enter upon theordinances and State [.aws rclating to building <br />above mentiond progrrty for <br />Applicnnt or Agent <br />Permitee nRme (print): <br />ancl <br />correct. I <br />,rr".Z-4* Zob <br />UNDER GROUND ) <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Building Sewer <br />Area/Storm Drain <br />I nterceptor/ Cla rifier <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 />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewer/Cap <br />Back FIow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release <br />FINAL l-ll.%Erlaloa <br />Notes Remarks Etc. <br />Li4rse Number:#Kofo-\--rufca <br />I