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PLU M BI NG.I NSPEGTOR RECORD APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DEI,CARATION I hqcby alfim undq pqalty of psjury that I m qmpt from thc CootracloE' Licw trw for tlrc following rcn (58.7031., Bwine ard Prcfsion Codc): Ary City or Couty which rcquin a pcrnh to coNtruct, alta, improvq danolbh or rcprir my strucluq prior to ts issuucc, also rcquis rhc applicet for such Frmit to frlc a signcd Btatmat rhst ha or slE b licosâ‚¬d pwril to thc prcvisioB of thc Contretor's Liccnscd Law (Chapt6 9. Commming with Setion 7000 of Division 3 of thc Buim md Prcfsions Codc) or that hc q shc is qmpt thftfrom ed thc basis for thc allcacd umption. Any violation of Sction 7031.5 by my applicmtforaFmitsbjetsthc spplicattoacivilpmltyofnotmorcthmfivehun&cddollm($500). _1. as owner ofthe property. or my employees with wages as their sole compersation, intended or offered for sale (Sec.7044. Business and hofessions Codc: The Contractor's License Law does not apply to an owner of the property who builds or improves thereon. and who does such wolt himself or herself or through his or her own employecs, provided that such improvonents are not intendod or oflhd for sale. If. however. the building or improvemeflt is sold within one )ryr of complaion. the Orrner Builder will have the burden of proving tha he or she did not build or improve the property for the purposc of sale). --1. as owner of the property, am exclusively contracting with licensed conlractors to construct the projed (Sec. 7044. Business and hrofession Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracls for such projects with a Contracto(s) licased pursuant to the Contractor's License Law). --larnexemptunderSection-.B'&P.C'forthisreason' f)o la. WORKERS' COMPENSATION DECLARATION I hereby affirm under pcnalty of perjury one of thc following declarations: _l have and will maintain a Certificate of Consent to Self:lnsure for workers' compensation. as pf,ovided for by Soction 3700 of the I-abor Code, for the performance of the work for which the pcrnrit b issued. _l have and &s by Section 3700 of the Labor Code, for the pcrformance of md policy numbo re: tthe work for C9 V Policy rl L _l certi& that in the pcrformance of the work for which this pcrmit is issued. I shall not employ any person in any manncr so as to become subject to the workers' compensation laws of California. and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the labor Code, I shall. forthwith comply with those provisions.. WARNINC: Failure to sccure workers' compcrsation coverage is unlawful, and shall subject an ernployer to criminal penalties and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation, damages as provided for the Section 3076 of the l-^abor Codc intcrest and attornsy's fees. D.,., \O rtS, >O \o* DECT AIU{TTON I haeby aflirm under pcnslty of perjury that I am licensod under provision of Chapto 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Number:tLicense W I hcby affim unda pcn8hy of pqjury thd the b s otrsrudbtr lading agmy 6r thc pcfoIrwc of thc wrt &r u&foh thb pmit b issucd (Se. 3097, Civ. C.). Lender's Name: Lender's Address: APPLICANT DECLARATION I hodqy affirm under penalty of perjury one of the following declarations: Demolition Perrnits-Asbestos Notification Federal Regulations (Title 40. Parl6) -Required lrtter of Notification _l certi& that the federal regulations rcgarding asbestos removal are not applicable to this project. -l ceni& that I have read this application and state that thc above I agree to comply with all City and County ordinances and State laws rclating to building construction, and of this City and County to erter upon the above mcntioned propcrty for Applicnnt or Agent D"t., Lolt6 relo UNDER GROUND Waste & Vent Water-Under floor Gas-Underfloor Building Sewer Area/Storm Drain I nterceptor/ Cla rifier TOP OUT I Waste & Vent l0 ul'?2 7 Water Piping Gas Piping Roof Drain Tub/Shower Test Rouqh Water Heater POOL/SPA P-trap/Drain Line Main Drain/Pool Pipinq Fill Line/Back Flow Pool Heater/Gas Line Miscellaneous Gas Service Water Service Lawn Sprinkler Sanitary SewerlCap Back FIow Device Roush Plumbins Final Gas Test Meter Release l FINAL wv INotes, Remarks, Etc. Permitee name (print): l\A-ttr, J. l\hr6wz