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PLUM BING.INSPECTOR RECORD <br />APPROVALS DATE ID/S!G.COMMENTS OWNEREUILDEIDELCARATIoN i <br />I hercby afftrm under Fnslty of Frjury thst I m cxerft ftom thc Coilmcl6' License law for thc following rc&sn (5&.70]1.5 <br />Busincss and Prcfession Code): Any City or County which r3quircs a lErmil to @nstruct. 8ltq. imprcvc. dcmlish or rcpair rny <br />structurc, friffi to its issuance. ds requircs the applicsnt for such Frmil lo filc I signcd stotercnl that hc or dlc is liccnsed purssnt <br />to the prcvisions of thc Contrscttr's Licenrcd L:s (Chaptq 9. Comrcncing with Sction 7000 of Division 3 of the Busircss 8nd <br />PrcfcssionsCodc)orthsthcorshciscrcmptthcrcfrcmandth€bssisfortherlhge{exemption. Anyviolationofssli,nT03l.5byany <br />applicsnt for I pemit subj$ts thc spplicail to s civil fEmlty of not mrc lhrn fivc hundrcd dolles ($500). <br />_l.as owncroflhcpropcrty.ormyernployccswilhrvagcsasthcirsolccorntlcnsation.s'illdolhcs'orkandlhcslnr:lurcisnol <br />inlcrrdcrl or ()ll'crcd frrr salc ( Scc.7044. Busincss antl l)rofl'ssions C}xtc': 'l'hc (irnlractor's Liccnsc [.aw docs not apply lo nn orvncr ol' <br />thc prrpny who huilds or irnprovcs lhcrcon. and who <locs such work hinrsclt'or hcrscll'or lhrough his or hcr own cnrployccs. <br />of conrphtion. thc Owncr tsuiklcr will havc thc bunlcn o[ proving thal l** or slrc did not huild or irrtprovc thc proprty ftrr thc purynrc of <br />sah). <br />_1. as()wncrof thc propcrly. anrcxclusivclyconlr:rcting rvith liccnsctl conlractorsto conslnrct thc pr<lject (Scc. 7()44. Busincss <br />and [hrll'ssionCodc: "l'hc('ontrnclor'sLiccnscl.awdocsnottpplyloanowncrofpropcrlywhobuildsorirttprovcslhcreon. <br />and who contracls frrr such ;lrojccts with a Contraclor(s) liccnscd pursuanl to thc Contractor's l-iccnsc Law). <br />-lalttcxcltlptundcr.Scclit,tl-.B'&P.C.lbrlhisrcason. <br />I )al t. ( )rr ltcr <br />WORKT'RS' COMPENSATION <br />DECLARATION <br />I hercby affirm under penalty of pcrjury one of the following declarations: <br />-l <br />have and will maintain a Ccrtifrcatc of Consenl to Self-lnsure for workers' compensalion, as providcd for by Scction 3700 of thc <br />l-abor Codc. for lhe performancc of the work for which thc pc'rmit is issucd. <br />-l <br />have and will maintain workers'compensation insurancc. as requircd by Section 37U) of thc l-abor Codc. for thc Jrcrformance of <br />thc work ttrr this is issucd. My workcrs'insurancc carricr und;xllicy numbcr arc: <br />Policy Ll zt <br />_l ccrtify that in the pcrfornrancc of the work for which this permil is issucd. I shall not crnploy any pcrson in any manner <br />so as to hccomc subject to thc workcrs'conl;lensation laws of California. and agree that if I should bccomc subjcct to thc <br />workcrs' cornpcnsation provisions of Section 37fi) of thc Labor Codc. I shall. forthwith conrply with those provisions.. <br />t <br />WARNING: Failure to sccurc workcrs' cornpcnsation coveragc is unlawful. and shall subicl an cnploycr lo criminal pcnaltics and <br />civil fincs up to onc hundrcd thousand dollars (S!U).UX)). in addition lo thc cost of co]npcnsalion. damagcs as provided for thc <br />Scction 3076 of thc Latnr Codc. interest and attorncy's l'ees. <br />,)ir,,.:Sff12a2o <br />LICT'NSED CONTRACTOR <br />DECLARATION <br />r liccnscd under provision of Chaptcr <br />liccnse is in full forcc and cffcct. <br />I hcrcby afhrm undcr pcnalty of pcrjury that I am <br />of the Business and Profcssions Code. and my I <br />9 (commcncing with Section 7ffiru) of Division 3 <br />INurnbcr: <br />CONSTRUCTION LENTTTNG AGENCY <br />I hercby allirm undcr pnalty of pcrjury thal lhcre is ! construclion lcnding aScncy for thc tf,rformnce of lhc work fo, which this lumil is <br />issucd (Scc. .1097. Civ. C.). <br />Lcndcr's Numc: <br />Lender's Address: <br />APPLICANT DECLARATION <br />I hcrchy aflirrn urrdcr pcnalty of pcrjury onc of thc lirllowing dcclarations: <br />Dcrnolit iorr Pcrnrils-Asbestos Notificat ion Fcdcral Rcgulal ions (Title 40. Parl6) <br />-Rcquircd <br />l-ctlcr of Notification <br />-l <br />ccrtify that thc federal rcgulations rcgarding asbcstos rcmovalarc nol applicable to this projcct. <br />_l ccnify that I have rcad this applicstion ud slotc lhat thc ilnve informdion is corcct. I a[re to comply wilh all Cilyand Counly <br />ordinanccs ond Strtc ljws rclating to building construclio[. rnd hcrcby autlx)rirc rcprcsnlativcs ofthis City and County to cntq u]nn lhc <br />atxlvc nrcntioncd propcrty frlr <br />Applicant or Agent <br />Pernrilee nanre <br />,,u,"SzipFq2^5 <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf loor <br />Building Sewer <br />ArealStorm Drain <br />I nterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rouqh Water Heater <br />POOL/SPA <br />P-traplDrain 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 FIow Device <br />Rough Plumbinq <br />Final Gas Test <br />Meter Release --_ <br />FINAL tl-21 ,4ln t )rI rht ,19 <br />Notes, Remarks, Etc. <br />Carricr:_ <br />Exoircs: <br />Liccnsc ctu*, b <br />,,,", Sc{t1l