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PLU M BI NG.! NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUTLDER DELCARATION <br />I hwby affm undq pqulty of Frjury thd I m cxmpt from thc Contractots' Licffi l2w for thc following lwn (6c.7031.5 <br />Buinss ard Prcfeion Code): Any City or County which rcguirB a pqmit to congrucl. altq. improvc &rnolkhor rt9air sy <br />structre. prior to its issumcc. also rcquirB thc applicmt for such permit to filc a rigncd statmmt tha hc or shc b licmcil pqrsrmt <br />to the provisions of thc Contrrtor's Liccnscd kw (Chspta 9. Commcncing with Sctiotr 7000 of Division 3 of thc Busin* dtd <br />Prcfeions Codc) or that hc or shc is cxmpt thqcfrom sd thc bcis for thc allcgcd crmplion. Any violstiotr of Scrion 703 1.5 by uy <br />applicant for a pcnnit subjcts thc applicut to a civil pcnalty of not morc lhm livc hundred dollrs ($500). <br />-1. <br />as owner ofthe property. or my employees with wages as their sole compensation. will do thework and the snrture is not <br />intended or offered for sale (Sec.70l4. Business and hofessions Code: The Contractor's Liccnse law does not apply to an owner of <br />the property who builds or improves thereon. and rvho does such wort hirnself or herself or through his or her own employees. <br />provided that such improvencnts re not intended orofkod for sah. I[, horvever. the building or improvematt is sold wilhin one ]car <br />of conpk:tiorL the Orvner Builder will have the hrdcn of proving thd he or she did not build or improve the propcrt'y for the purposcof <br />sale). <br />-1. <br />as owner of the prop6ty. am exclusively contracting with liccnsed contractoni to construct the project (Sec. 7044. Business <br />and hoftssion Code: The Contractor's License Law does not apply to an o\r'n€r of property who builds or improves thereon. <br />and who contracls for such projects rvith a Contraclo(s) licensed pursuant to the Contraclor's License Law). <br />_l am exempt under Section_B. & P.C. for this rcason. <br />l)ntc:0wner:_ <br />WORI(ERS'CO <br />DECLARATION <br />I hereby affirm under penalty of pcrjury one of the following declarations: <br />-l <br />have and s.ill maintain a Ccrtificate of Consent to Self-lnsure for workers' compensation. as provided for by Section -1700 of the <br />Labor Code. for the pcrformance of the wo* for which the permit is issued. <br />_l have and will maintain rvorkcrs' compensation insurance. as required by Section -3700 of the Labor Code. for the performance of <br />the work for u'hich this permit is issued. My workcrs' compersation insurance carrier and policy number are: <br />Policy l;r pir.es: <br />_l cerrify that in the perforrnance of the rvork for rvhich this perrnit 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 the <br />rvorkers' compensation provisions of Section 3700 of the Labor Code. I shall. forthwith comply rvith thosc provisions.. <br />\VARNING: Failure to secure u'orkers' compensation and <br />civil fines up to one hundred thousand dollars ($l the <br />Section .3076 of Labor interest and attorney's <br />t)[('1,ARA't tON <br />I hereby affirm under penalty of pcrjury that I am licensed under p,mvision of Chapter 9 (commcncing with Seaion 7000) of Division 3 <br />of the Business and Professions Code. and my liccnse is in full force md effect. <br />At-\-oc:1License Class:- <br />\\ <br />I hreby aflirn undo Jrcnahy ofperjury that thsc is a construclion lcnding agency for the pafonnance ofthe work for u'hich this pmnit is <br />issued (56. -1097, Ci\'. C.). <br />l,cnder's Name: <br />- <br />Lcrrrlcr 's r\tltlr css <br />APPLICAN'I' DECLARATION <br />I herelry aflinn under penalty of perjury one of the follorving declarations: <br />Demolition Permits-Asbestos Notification Federal Regulations ('title 40. Parl6) <br />-Required <br />Letter of Notification <br />_l cedify that the lbJeralregulations rcgarding asbestos removal are not applicable to this project. <br />_l certify that I have read this application s,ith all City and County <br />ordinances and State Laws relating to and County to enter the <br />above mentioned property for <br />Applicnnt or Agent <br />Pt'rmitee nrnre <br />purposes. <br />rl <br />u t) <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />I nterceptor/ Cla rifier <br />TOP OUT <br />Waste & Vent <br />Water Pipins <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOL/SPA <br />P-trap/Drain 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 Sewer/Cap <br />Back Flow Device N\n\ <br />Rough Plumbing kEnlnt{A'JN,\) <br />Final Gas Test \, <br />Meter Release /\ <br />F!NAL <br />Notes Rema Etc. <br />a <br />Carrier: <br />\\, <br />Dnte:_oq_-___\l-- <br />T <br />(-t+ -7a <br />[r- 19'74 3ffi