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PLUM BING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNEN, BUILDER I'ELCA-RATION <br />I hcrcby affrm undcr pcmlty of pcrjury thst I m cxempt frcm ttrc ContnctoN' Lbens [rw for thc followiog tr@n (Sc.7031.5 <br />Busincss snd Profcssion Code): Any City or County which rcquires 8 pcmil to construcl, ahs, iqmre, dcmlish or rcpair any <br />structurc. prbr to ils issuarce, drc rcquires th€ applkant for such Frmit to lilc 8 sigred stalemnl that hc or slE b licetrsd pusutrl <br />ro thc pmvlsions of thc Conlrrctor's Licenrd [rw (Chspler 9, Comrcing with Selion 7000 of Division 3 of thc Busimss ud <br />Prcfcssk ns fue) tr that he or shc is cxerpt ttmfrom and lhc basis for thc sllcgcd eremp(ion. Any violalion of S*tbn 703 I .5 by sny <br />applicsntforapcrmitsubjElsthc spplicsnlloscivilpcnalyofnolmrcthsnfivehundrL{dollus(S5m). <br />_1. Bs owner of the profrcrty. or my cmployees with wages es their solc compcnsation. will do thc work and the stnrcture is not <br />intendcd or offercd for sale (Scrc.704+. Busincss and hofessions Code: The Contractor's Liccnse Law does not apply to an owner of <br />thc propcrty who builds or improves thcrcon. and who does such work himself or hcrself or through his or her own employees. <br />provided that such improvenrcnls arc ncrt inlended oroffc"rcd for sale. lf. however. the building or irproverEnl is soH within one )Gar <br />of complction. thc Owncr Buitder will havc the btrden of proving that he or she ditt not build or inqrmve the prof,erty for thc purpsc of <br />sale). <br />_1. as owner of the propcrty. am exclusivcly contracting with licenscd conlraclors to construct thc project (Sec. 7W, Busincss <br />and Pmfession Codc: Thc Contractor's Liccnse Law docs nol apply lo on owner of propcrty who builds or improves thereon. <br />and who contracts for such projc.cts with a Contracto(s) liccnsed pursuant to thc Contractor's Licensc kw). <br />-l <br />a:n cxcrnpt urttlcr B. & P.C. for this reason. <br />l)1.('l.AR \'l'loN <br />I hcrcby alfirm undcr pcnalty of perjury one of thc following dcclarations: <br />_l havcandwill rnaintainaCertilicatcofConscrrtto.Scll'-lnsurclirrworkcrs'compcnsation.as providedforhyScctiott.iTfi)ol'lhc <br />l;rhor (bdc. fbr thc pcrforrnance of thc work lbr which thc pcrrnit is issucd. <br />_t havcandwill rrraintainworkers'conrJrcnsalioninsurancc.as rcquirctl hySection3T(X)ofthcLaborCodc.t'orlhcpcrfornranccof <br />thc work lbr which this grcrrnit is issucd. My workers' cornlrcnsalion insurancc carricr and policy numbcr are: <br />Policy Numbcr: ExPircs: <br />_l ccrtify that in thc Jrcrformance of the work for which this prmit is issucd. I shall not empkry any Frerson in any mBnner <br />so as to become subject to thc workcrs' comgrcnsation laws of California. and agrce that if I should bccome sublct to lhc <br />workcrs' compcnsation provisions of Scction 3700 of the t-abor Codc. I shall, forthwith comply with those provisions.. <br />WARNING: Failurc to sccurc workers'comlrcnsation covcrage is unlawt'ul. and shall suhict an employcr to criminal pcnaltics and <br />compcnsation. damages as provided for thccivil fines up lo onc hundred thousand to the cost of <br />Scclion 3076 of lhc Latnr intcrcst <br />l)li('l.ARA'l'l( )N <br />I hereby affirm undcr penalty of perjury that I am licenscd under provision of Chapter 9 (comnrcncing with Section 7m0) of Division 3 <br />of thc Business and Professions Code, and my license is in full force and cffc'ct. <br />Liccnsc Numhcr: <br />Dale:- <br />W <br />I hcrcby nffirm undcr trcnoltyof Jrcrjury that thcre is a q)nstruclion lcnding agcrry for thc pcrftrmne of lhc work for which this lrcrmil is <br />issucd (Se. 3097, Civ. C.). <br />kndcr's Nrm: <br />[rndcr's Addrcss: <br />APPLTCA NT DECL ART{'I'I(IN <br />I lrn-$y aflirrn undcr Jrcnalty of perjury onc of thc following dcclarations: <br />Dcnxrlition Pcrmits-Ashcstos Notification Fcdcral Rcgulations (Titlc 40. ['afl6) <br />-Rcquircd <br />lrttcr of Nolification <br />rcgarding asbcslos rcmovalare nol applicable to this projcct. <br />state that lhc atnve infonnalion is correcl. I agrce to conply <br />representatives of this City <br />! <br />with all Ciry and County <br />and Cou;Uy lo cntcr uJnn thc <br />atxrvc rrrcrrlioncrl propcrty for <br />Applicnnt or Agent <br />I'ernrilee nanre <br />construction. and hcreby aulhoriz.c <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf loor <br />Buildinq Sewer <br />ArealStorm Drain <br />I nterceptor/ Clarifier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower 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 SewerlCao <br />Back Flow Device <br />Roush Plumbinq <br />Final Gas Test <br />Meter Release I -)FINAL t/ /t1/ 4pz,// <br />Notes, Remarks, E{c.2 Y- <br />Carrier:- <br />l.icense <br />Contraclor: <br />/0V(