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PLU M BI NG.INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION
<br />I hccby allirm undo pcmlty of pcrjury thd I .m cxcmpt liom th€ ContracloB' Liccns Law for thc following rcasn (Ss.7031.5
<br />Busincss ard Pmfcsion Codc): Any City or County which rcquircs a ;mit to sn{rucl, alts, imprcvq dcmlish or rcDair 8ny
<br />structurc, prhr to its isMrcc, als Eq[iffi lhc spplicant for such Imil to lilc a signc{ statcmnt lhrt hc or shc lr licosd pursmt
<br />to thc pmviiiotri of thc ContrctG'! Lianscd taw (Chapta 9, Commcrcing with Scction 7000 of Division 3 of thc Businc$ 8nd
<br />PmfcssionsCodc)orthathcordEirqcmptthcrcfiomandthcb&iirforthcallcgcdcxctrrption. AnyviolatiooofSelionT03l.5byany
<br />applicantforapcmitsbjclsthc.pplicsnttoacivilpcEltyofmtmrclhrofivchundrcddollars($500).
<br />_1, as own€r of the proFrerty, or my employees with wages as their sole compensation, will do the work and thc structure is not
<br />intended or ofFered for sale (Sec.7044, Busircss and Professions Code: 'l'he Conlractor's License Law does not apply to an owner of
<br />the property wtn buil& or Lnproves thereoq and wtn does such work himself or herself or thmugh his or her own employees,
<br />provided that such impnovements are not intended or offered for mle. l(, tnwever. the htrilding or improvernent is sold within one )csr
<br />of completion, the Owner Builder will tr,ave the burden of proving thal hc or she ditl rnt build or inqrmrrc the prop,erty for thc purynse of
<br />sale).
<br />_1, as owner of the property. am exclusively contracting with licensed contraftorsto construct the pr<rject (Sec. TM4,lJusiness
<br />an owner of property who builds or improves thereon,ard Professkrn Code: 'l'he Contractor's does not lo
<br />and u,ho contracts for such t<l the Contraclor's [-icense Law).
<br />_l am exempt &fur this reason.
<br />DECLARATION
<br />I herehy affirm under penalty of perjury one of the following declarations:
<br />-l
<br />have and will maintain a Certificate of Consent to Self-lnsure for workers' contpensalion, as provided for by Section 3700 of the
<br />l"abor Code, for the performance of the work for which the permit is issued.
<br />_l have and will maintain workers' compensation insurance, as required hy Section 3700 of the Lahor Code, for the performance of
<br />the work for which this permit is issred. My workers' compensation insurance carrier and Jnlicy number are:
<br />Policy Number: Expires:
<br />_l certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner
<br />so as to become subject to the workers'compensation laws of California, and agree that if I should become subject to th€
<br />workers' compensation provisions of Section 3700 of the Labor Code, I shall, forthwith conrply with ttnse provisions..
<br />WARNING: l:ailure to secure workers'
<br />civil fines up to one hundred thousand
<br />coverage is unlawful, and shall subject an emfloyer to criminal penalties and
<br />(sl lhe cost of as provided for the
<br />LICENSED CON I RAC'I'OR
<br />DECI ATI,I'I'ION
<br />I hercby aflirm under penalty of perjury that I am licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3
<br />of the Business and Professions Code, and my license is in full force and effect.
<br />License Class: License Numher:
<br />Date: Contractor:
<br />W
<br />I hercby aflirnr under 1Emlty of perjury that thqe ii a onstruction lcnding agcncy for the pofomancc of thc work ,br which this Jrmit is
<br />ismed (Sa. 3097, Civ. C.).
<br />Lcndcr's Name
<br />Lender's Address:
<br />APPLICAN DTCI ARA'TION
<br />I lrreby aflirm under penalty of perjury one of the lbllowing declarat ions:
<br />Denrolition Permits-Asbestos Notification I;ederal Regulations ('l'itle 40, Part(r)
<br />-Rertuired
<br />Letter of Notification
<br />-l
<br />certify that the federal regulations regarding asbestos removal are not applicable to this project.
<br />_l certify that I have read this application and state that the atnve information is corlgct. I agree to comply with all City and County
<br />ordinances and State Laws rclating
<br />atxlve mentiorrcd property for
<br />Applicarrt or Agent
<br />Permltee nanre
<br />arxl of this City and County to enter u[x)n lhe
<br />UNDER GROUND ltt=='l-^ ,ln /
<br />Waste & Vent lr1/17L{ryx( )rwv Q(
<br />Water-Under floor
<br />Gas-Underfloor
<br />Buildinq Sewer
<br />ArealStorm Drain
<br />I nterceptor/ Clarifier
<br />TOP OUT I
<br />Waste & Vent I '-"''-
<br />Water Piping luL-r',-K-t
<br />Gas Piping 'i,n
<br />Roof Drain
<br />Tub/Shower Test
<br />Rough Water Heater
<br />POOUSPA
<br />P-trap/Drain Line
<br />Main Drain/Pool Pipinq
<br />Fil! Line/Back FIow
<br />Pool Heater/Gas Line
<br />Miscellaneous
<br />Gas Service
<br />Water Service
<br />Lawn Sprinkler
<br />Sanitary SewerlCap
<br />Back Flow Device
<br />/
<br />Rough Plumbins / /7 t ruDt "LI,DU:7
<br />Final Gas Test I
<br />tt It /r,
<br />F!NAL lJ UYA guLuq {6t\
<br />Noteg, ff,enpfks, Etq.1
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<br />I ,(/t2//(/ t /V//L /r,,I I *L4rW- /6q
<br />'l/ /t-s //q, tbit,4az_/dv
<br />rlJ'il/1 Pl',h4 'a.rdIa
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<br />a
<br />DaV_/
<br />A -a
<br />Meter Release
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