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PLUM BING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNEN,BUILDERDELCARATION 'I hErcby sflirm undcr pcnslty of perjury rhrt I m cxcmpt &om thc ContrdctoG' Lbens hw for thc following rc&sn (Ss.7031.5 <br />Busincss rnd hofcssion Codc): Any City or County which rcquircs I lrrmil lo @nstruct, altcr. improrc, dcmlish or rcpah my <br />structurc. prior to its issurre, olso rcquircs thc rpplbmt for sch lrcmil to lih s signcd statemnl that hc or slE is licenred ptmuant <br />to thc trcvisions of thc Conrettr's Licrned [:w (Chrpter 9, Comrercing with Setion 7000 of Divisbn 3 of thc Busircss md <br />Prcfe$sions Codc) or thst hc q she is cxcnpl thcrefrcm and the bssis for the sllcgcd cxcmprion. Any violation of Sec-rion 7031.5 by tny <br />rpplicsnt for I pgtnit subtrts the applicant to I civil pemlty of nol mE lhm livc hundrcd dollm ($500). <br />_1. as owner of the proF,erty. or my cmployecs with wages as thcir solc compensation. will do the work and the structurc is not <br />intendcd or offcrcd for salc (Scr.7044, Busincss and Professions Code: The Contractor's License hw does not apply to an owncr of <br />the propcrty wlro builds or inprovcs thereon, and who does such work himsclf or hcrself or lhrough his or her own employees. <br />provided that such improrrnrnts are not intcndcd or offcrd for sah. lf. however. thc bruilding or improvetrEnt is sold wilhin one )rcar <br />of comptction. the Owner Buildcr will harrc thc burden of proving lhat hc or shc did not truild or improve thc proJrcrty for thc purF)sc of <br />sah). <br />_1. as owncr of the propcrly. ant cxclusivcly contracting with liccnsccl conlraclrlrs lo construct lhc projccl (.Sec. 70.{4. Iltrsincss <br />and t,nrll.ssion Codc: 'l'hc Contractor's l-iccrrsc l-aw docs nol af,ply lo an owncr of'propcrty who huiltls or inrprovcs lhc'rcon. <br />and who contrilcts for such pr<rjccts with a Conlractor(s) liccnscd pursuanl lo lhc C'ontractor's l-iccnsc [-aw). <br />-lalncxcmr,tunderScctitln-.B'&P.C.frrrthisrcastln.( )rvnrr: <br />WORKERS' COII| PFNSA'I'ION <br />DECI ARATION <br />I hercby alfirm undcr pnalty of pcrjury onc of thc l'ollowing dcclarations: <br />_l havc und will nraintain a Ccrtilicatc of Conscnt to Sclf'-lnsure lbr workcrs'cornpensation. as providcd for by Scction 37fi) of thc <br />labor Codc. for thc pcrforrnance of the work for which thc pcrrnit is issucd. <br />_l havc and will maintain workers'comJrcnsation insurancc. Bs rcquircd by Scction 37fi) of thc labor Code. for thc 1rcrf<lrmance o[ <br />the work for which this pcrmit is issucd. My workcrs' comlrcnsation insurancc carricr and plicy numbcr arc: <br />Policy Nuntbcr: ['ixPircs: <br />_l ccrtify that in thc pcrformance of thc work for which this pcrrnit is issucd. I shall not cmploy any Frcrson in any milnner <br />so as to hcconrc subjccl to thc workcrs'compcnsation laws of California. and agrcc thal if I should bcconrc subjcct to thc <br />workcrs' conrpcnsation provisions of Scction 3700 of the Lahrr C--odc. I shall. forthwith comply with thorrc provisions.. <br />WARNING: Failure to sccure workers' conrpensation coverage is unlawful. and shall subject an cmploycr to criminal pcnalties and <br />civil fincs up to orrc hundrcd thousand doltars ($100.m0). in addition to tlrc cost of comlrcnsation. damages as provided for the <br />Section 3076 of the L:bor Codc. interest and attonrcy's fees. <br />Date: Applicnnt: <br />LICENSED CONTRACI'OR <br />DF'CLARATTON <br />I hcrcby allrrm undcr pcnatty of pcrjury that I am ticcnscd undcr provisiort of Chaptcr 9 (comnrcncing with Scction 7UX)) of Division 3 <br />of the Busincss and Profcssions Codc. arxl nry license is in full tbrce ard cl'fcc'|. <br />Liccrtsc Nurnbcr: <br />l)alt' ('olllritclor. <br />C(TNSTRUCTION I T'NDIN(; AGFNCY <br />I hc.rcby aflirm undcr lrcnalty of fErjury that tlrcrc is a construction lcndinS qcncy for lhc lrcrforlurct ofthc $ork for shich this F]mil is <br />issucd (Scc. 1097, Civ. C.). <br />kndcr's Namc: <br />APPLIC {NT DF'CLARATI(IN <br />I hcrcby allinn undcr pcnalt y of pcrjury onc of t hc tbllowing dcclaral ions: <br />Dcnxrlit ion Pcrnrits-Asbcslos Notificat ion Fcdcral Regulat ions ('l'it lc 40. Parl6) <br />-Rcquircd <br />lrtter of Notilicalion <br />-l <br />ccnify that thc fcdcral rcgulations rcgruding asbcslos rcmovsl ure nol applicublc to lhis pmjccl. <br />_l ccnify lhat I h.vc rcsd lhis 0pplication and st8tc lhnt thc alnvc inforroIioD is corcl. I agxe Io comply wilh all City end County <br />ordinarccs and SIatc Laws rclaling to huitding construction. and hcrchy authorizc rcprcsnlalivcs of lhis Cily and Counly to cnts ulnn lhc <br />atnvc nrntiomd pm1rfly for insFction purF)ss. <br />Appllcant or Agent Signature: <br />Pemlle mmc (prina):- <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf loor <br />Buildinq Sewer <br />Area/Storm Drain <br />I nterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Pipino <br />Gas Pipins <br />Roof Drain <br />Tub/Shower Test <br />Rouqh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />Main Drain/Pool Pioino <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 />Rouqh Plumbinq <br />Final Gas Test <br />Meter Release ll t A <br />FINAL w I '//2 vtw( <br />Notes, Remarks, Etc <br />,l <br />Date:_