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APPROVALS DATE !D/SIG.COMMENTS OWNER BUILDER DET CARATION I hcby aflim undo pcnalty of pcrjury thrt t m cxcmpt &om thc CoitrutoB' Licre L:w for thc following @n (Sc.7031.5 Buincs and Prcfxion Co&): Any City or Couty which rcquire a pamit to onstruct, altc, imprcvc. &nolish or rcpoir my struGluc, prior to its isumcc. abo rcquirB thc eplicilt for such pmnh to filc I signcd stdmat th0r lE or shc b licaEcd plsmt to thc provisioN of thc Contractor's Licogcd trw (Chapt6 9, Commmcing with Scriotr 7000 of Division 3 of thc Buineond PDfcsiom Code) or that hc or shc b qmpt thGcfrom ed thc bosis for thc allcacd cxoption. Any violation of Sctiotr 7031.5 by uy applicutforap6mitsubjersthc spplicuttoocivilpaaltyofnotmorcthefivchundrcddollss($500). _1. as owner of the property. or my employees with wages as their sole compensation. willdo the work and the structure is not intcndcd or offerd for salc (Sec.7044. Business and hofessions Code: The Contractor's Lice'nse law does not apply to an owner of the propoty who builds or improves thcrqrn. and who does such work himself or herself or through his or her own employees. provided that such improvonents are not intended or offcrod for sale. l[, howet/cr, the building or improvement is sold within one ]ryr of complaion. the Ov*ner Buildcr will have the hudcn of proving that he or she did not build or improve the propory for the purpose of sale). -1. as o\+'ner of the propcrty. am exclusively contrac'ting with licensed contracton to construct the project (Sec. 7044. Business and ttofession Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and rvho contracls for such p,rojccrs with a Contractor(s) licensed pusuant to the Contraclor's License Law). -l am exempt under Section-, B. & P.C. for this reason. !)alc WORKERS' COMPENSATTON DECLARATION I hereby affirm under pcnalty of pcrjury one of the following declarations: _l have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation. as provided for by Section 3700 of the Labor Code for the performance of the wort for which the pernrit b issued. _l have and will maintain workers'as by Section 3700 of the Labor Code, for the performance of and policy numbcr are:the rvork ";[ilW'tlissued Policy oz I _l certifu that in the perforrnance of the work for which this permit is issued. I shall not employ any person any manner so as to bccome subject to the workers'compcnsation laws of California and agree that if I should become subject to the workers' compensation provisions of Sertion -3700 of the tabor Codq I sh8ll. forthwith comply with thosc provisions.. WARNING: Failure to sc.cure workers' compensation coverage is unlawful. and shall subject an employer 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 3076of $e t Fr 6d..interest and attorney's fees. ,,,,, lo le L I 'l,o \oApp,icanr: I I LIcENSED coNrRACroR DECI.ARATION I hereby alTirm under penalty of perjury that I am licenscd under provision of Chapter 9 (comrnencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full fiorce and effect. License Numbcr: CONSTRUCTION LENDINC AGENCY I h@by amrm unds pcnalty of ptrjury that thre is 8 construction loding agacy for thc psfomuce of thc work for which this pqmh b issucd (SG. 3097. Civ. C.). Lender's Name: Lender's Address: APPLICANT DECII\RATION I hcr*y afrnn under penalty of ffiury one of the following declarations: Dernolition Permits-Asbcstos Notification Federal Rcaulations (Title 40, Part6) -Rcquired l-cttcr of Notific*ion ._l certi& that the federal regulations regarding asbcstos rernoval are nol applicable to this project. -l certi& that I have read this application and state that the above correct. I agree to cornply with all City and ordinances and State Laws relaing to building construction, and representatives of this City and above mentioned property for Applicent or Agent Pernritee nRme o ( enler oi UNDER GROUND Waste & Vent Water-Under floor Gas-Underfloor Buildinq Sewer ArealStorm Drain I nterceptor/ Cla rifier TOP OUT Waste & Vent Water Pipinq Gas Piping Roof Drain Tub/Shower Test Rouqh Water Heater POOL/SPA P-trap/Drain Line Main Drain/Poo! Piping Fill Line/Back FIow Pool Heater/Gas Line Miscellaneous Gas Service Water Service Lawn Sprinkler Sanitary Sewer/Cap Back FIow Device .-, Roush Plumbins ///n< t %?o .{1 ffii) Final Gas Test 't/ Meter Release I a ^ ,L.J FINAL lLlX 'k)vtT{o I Notes, Remarks, Etc. PLUM BI NG.I NSPECTOR RECORD d Owner: w