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PLUM BI NG.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DETTARATION I hccby aIlim unda paalty of pcrjury that I m cxcmpt ftom thc ContractoE' LiccE [rw for thc following rcen (Se?03{.5 Busincs and Profsion Codc): Any city or County which rcquirc a pcmit to consiruct, altq, improvq dqnolish or rqir sy structurq Fior to its issurec, also rcquirc thc ,pplicmt for such pcmit to filc 8 sig,ncd stdcmt thal hc or slrc b licascd puuam to thc provisioN of thc Contrrctor's Licoscd law (Ch.pt6 9. Commocing wirh Sction 7000 of Division 3 of thc Buine md PrcfNions Codc) or that hc or shc is cxmpt th@ftom ed the b8is for thc allclcd crmption. Any violaiion of Sctbn 7031.5 by my sp,plicant for 8 pmit subjEts thc applient to a civil penslty of not morc the livc hundltd dolles ($500). _1. as owner ofthe property. or my employees with wages as their sole comperualion, willdo thc work and the stnrctrne b not intcndod or offcred for sale (Se.7044, Brsiness and hofcssions Code: The Contractor's Liccnsc l-aw does not apply to an owner of the propcrty who hrilds or improve ttrcrcor\ and who does such work himself or hcrsclf or through his or her own employecs. provided that such improvanrents are not intendod or offqcd for sale. lf, howerrer, the building or improvfiEnt is sold within one )â‚¬ar of complaion, the Omer Buildo will have the hrntcn of proving tha he or she did not build or improve the propaty for thc purpose of sale). _1. is owner of the Fopcrty. arn cxclusively contracting with licerrsed contraclos to consitruct the project (Sec. 7044. Brsiness and Prrofession Code: Thc Contractor's License Law does not apply to an ownâ‚¬r of propcrty who builds or improves thereon, and who contracts for such projccts with a Contracto(s) licensed pursuant to the Contraclor's Licctrse taw). -l am exempt under B. & P.C. for this reason. WORKERS' COMPENSATION DECLAR/tTION I hereby allirm under pcnalty of perjury one of the following declarations: _l have and will maintain a Certificate of Conscnt to Self-lnsurc for workers' compcnsation. as p,rovided for by Section 3700 of the Labor Code. for the perfonnance of the work for which the permit is issued. _l have and will rnaintain workers' compensation insurance. as required by Section -1700 of the Labor Code. for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: Policy 77 t /t/rl _l certi& that in the pcrformance of the work for which this pcrmit is issued. I shall not employ any person in any manner so as to become subjcct to the workers'compensation laws of California" and agree that if I should becomc subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall. forthwith comply with those provisions.. WARNING: Failure to secure workers' compcnsation coverage is unlawful, and shall subject an anployer to qiminal panalties 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 tabor Code interest and attorney's fecs. d I hereby affrrm undcr penaltyof pcrjury that I am liccnscd Chaptcr 9 (commencing with Section 7000) of Division -i of the Business and Professions Code. and my liccnsc is in full force and effect. Licensc floto. I hereby affrnn under penalty of perjury that there issued (Sec. 3097. Civ. C.). agexcy the performance of the work for which this pcrmil b lrnder's Name: Lcnder's Address: APPLICAI\T DECLARATION I herety aflirm under pcnalty of perjury onc of the following declarations: Dernolition Permits-Asbcstos Notification Federal Regulations (Title 40. Part6) -Required letter of Notification -t cdiry thd thc fcdcal rcgulstioB rcgrding abetos mvsl ffi trot epliclblc to fiis pmjEr. -l cqriry thar I haw rad thb application ad st8tc that thc abovc infomdion is con6t. I agre to @mply with .ll City ed Couty ordinmce md Statc Lrw rclairg to building onstuuciion, md h@by 8uthoria rqEwntrtivc of thb City and Coutrty to mts upon thc above mentioned property for Applicent or Agent Perrnilee nRme W ^,,,f l'K'fu UNDER GROUND Waste & Vent Water-Under floor Gas-Underfloor Building Sewer ArealStorm Drain I nterceptor/ Cla rifier TOP OUT Waste & Vent Water Piping Gas Pipinq 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 SewerlCao Back Flow Device Rouqh Plumbinq Final Gas Test Meter Release ,,4 FINAL //.)f,a Z 1!r ,l llog "ru Notes, Remarks, Etc. tu 0