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PLUM BING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS 0wner-lluildcr Declaration <br />I hcrcby sffirm undcr pcElty of p.rjury lhat I am cxempt fornr thc Contradors' License kw for the following rcon (se.7ol !.5 BsitrGs <br />md Profcssion Codc): Any City or Couty which rcquirB a [Emit to coNtrucl. altcr. improvc. dcmolish or rcpair rny structuc. prtrr to iti <br />issuatrcc. also rcquir6 thc spplicant for 3uch pmit to filc I signcd statflcnt that hc or shc is liccBcd puBuilt to thc prcvisiotrrf thc <br />Comractor's Liccrocd Llw (Chlpter 9, Commcncing with Setion 7000 ofDivision 3 ofthe Busines snd Prof6cio6 code) or that hc or <br />shc is cxcmpt rhgcfrom 8nd thc b8k for thc sllc8cd cxcmption .Any violarion ofsccrion 70-l l.J by sny applicanr for a pemil lubjccts thc <br />applicsnt lo r civil pcnllIy ofnot morc th.n fivc hudrcd dollm ($500). <br />_1.8 owo6ofthcprcpcny.ormycmploycBwithwl86aithcirsolccompcmtion.willdothcworkedthcrtruci[cisnotintqdcd <br />or offcrcd for sle ( S{ 7044, Busin6s snd Profcssions Codc: Thc Contractor's Lic.mc Law docr not apply to an owncr ofthc prcpcdy <br />who builds or improvG thscotr. ud sho do6 srch wort hirelf or hmclf orrhrcugh his orhrown cmploye, prcvidcd that such <br />improvcmcnts arc not intcndcd or offscd for srlc. If, howcvs, thc building or improvcmcnt h sold within onc ycar ofcomplction. thc <br />OwB-Builds will havc thc burdo ofprcvin8 thst hc or 3h. not build or improvc for thc purpolc ofsalc). <br />_1. s own6 of thc propcny, m cxclulivcly contncling with liccorcd contEctoG to costruct thr projcct ( Se. 7O44. Buinos ud <br />Profcsrion Codc: Thc Contraclor'3 Lic.nsc law doe not apply to an ownor ofproperty who builds or inprovca th?r@n . ond who <br />cont.lds fo. ruch proj*ts wih a Cont.actor(s) liccnscd puBu6nt to Contradoa s Liccns. kw ) <br />I n & P.C.tcason. <br />Dalc: <br />I hcrcby affirm undq pcnalty ofperjury onc ofthc <br />_ I havc and will mainlain. Ccnificslc ofConsent lo Sclf-lnsure for worliers' conrpensation. as provided for by seclion l7o0 ofthe <br />l,abor Code. for thc performance ofthe work for lvhich thc pennit is issued. <br />. l have and wrll nlarnlarn workers conpensatron insurance, as requrred by Sectron lT00 of lhe l.abor ('odc. lbr lhe perlbrnrancc oflhe <br />work for whrch thrs perntil is rssued My workers compensation insurance canier and policy nurnbcr arc: <br />Cmicr:_ <br />Policy Number: Expires: <br />(This scclion nced not be complcted if rt* po.ir i, fo. On" tr,rn*"a Oottm | $ t OO) or tess) <br />thc hbo, Code. interGt .nd lttomcy's f6 <br />LICENS}:D CONTRACTORS DE('LARATION <br />I hcreby amrm uodcr penahy of perjury lhst I am liccnscd undcr provision ofChepter 9 (comrncncing wilh Scction 7000) of frivision -1 of <br />thc Busincss and Prof6sions ('odc. and my liccnse is in full forcc and cffect. <br />Liccnsc Class: l"iccnse Numbcr <br />Dstc:Contractorl <br />CONSTRUCTION LENDING AGENCY <br />I hcreby amm undcr peuhy of pcrjury thal lhcre is a construction lcnding rgcncy for thc pcrfomncc of thc work for which this pqrnit is <br />issucd (Scc. 1097. Civ. ('.). <br />Lender's Namc: <br />Lends s Addrcss. <br />APPLICANl'S DT]CI,ARA'I'TON <br />I)cnNlilion Pcrmils-Asbcslos Notification ledcral Rcsulati()ns ( I itle 40. Pan 6) <br />Re(luired l.ettcr of Notifi cati(Jn <br />_l c.rtify that thc fcdcrsl regulatioN rcSrding sbGlos rcmoval arc not applicsblc to this projat. <br />_ I ccniry that I havc rcad lhis application and state thal thc abovc infomation is corecl. I agrcc to cornply rvith all City and County <br />ordiuncG af,d Strlc Lrws rclrling to <br />ahovc mcntioncd propc(y for <br />coNtruclion. and hercby suthorir rcprGentalivcs ofthis City and Counly to cnlff upoo thc <br />UNDER GROUND <br />Waste & Vent <br />Water-Underfloor <br />Gas-Underfloor <br />Building Sewer <br />Area/Storm Drain <br />I nterceptor/ Clarifier <br />TOP OUT <br />Waste & Vent <br />Water Piping <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 Piping <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Misc <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewer/Cap <br />Back Flow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release <br />n/^)/ <br />FINAL L//J / /fl r *, aa <br />Notes, Remarks, Etc.u <br />nlanner so as lo <br />Dalc: <br />WARNINC Failure lo <br />Applicant or agent sig.: <br />Permillee namc (prinl): <br />_Datcl_t ltf r;