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PLUMBING.INSPECTOR RECORD <br />APPROVALS DATE !D/SIG COMMENTS ()lvnq-Buildcr Dcclaralion <br />I hereby affirn under peffilly ofperjury lhat I am exempt form lhe Contractors' License law for the following roson (sec 70] 1.5 Busin6s <br />and Profcssion Code): Any Ciry ot County which rcquircs a permit to coNtruct, altcr. itnprovc. dcmolish or rspair any slruclurc. prior to ils <br />issuancc. also requircs lhc applic6nt for such pcrmil lo filc a signed statcmcnt thal he or shc is liccnscd puGuant to thc provisioN oflhe <br />Conlrsctot's l"aceBed Law (( hapler 9. Commencing wilh S@tion 7000 ofDivision I ofthe Business and Prol6sions Code) or that hc or <br />shc is excmpt thcrcfiom and thc basis for lhc allcged cxcmption .Any violation of Sstion 703 1.5 by any applicanl for a pcmil subjccts thc <br />applicanl to a civil penahy ofnot mor. than fivc hundrcd dollars ($500). <br />_1. s owncr of thc prcpcny. or my cmployG with wrg6 as th.ir solc compcmrtion. will do thc work and thc structuc i! not intcndcd <br />or offered for salc ( Scc.7044, Busin6s snd Profcssions Codcr Thc Contractor's LiceBe Law docs not apply to an ownc. ofthc propcrly <br />who builds or improvG lhcrcon. and who do6 such work himsclfor h6clfor lhrough his or ho own cmployce. provid.d thEt such <br />improvcmctrls arc rct intcndcd or ofTsad for srlc. If, howcver. thc building or improvcmcnl k sold withh onc ycr ofcomplction. thc <br />Owncr-Builds will hsvc thc burdcn ofproving that hc or shc nor build or improvc for thc purposc ofsalc). <br />_1. 6 own6 of thc propcrty, m crclusivcly conlractinS with liccBcd conlractoE to coBtruct thc projsl ( Ss. 7044. B6io6s md <br />Profcssion Code: Thc Contr.ctot's Liccnse lrw does not rpply to sn owncr ofpropcrty who builds or improve thereon , tnd who <br />contracts for such projels wilh a Contraclor(s) licansed pursuant to the Contractor's t w.). <br />I am cxcmpt undcr Scction <br />Date: <br />&rcason. <br />_C)wnq::1^ <br />I h6cby amm under pcnally ofpcrjury onc <br />IhaveandwillmainlainaCe.tificateof(onsenlloSelf-lnsureforworkers compensation.as prcvidedlorbySeclion:]700ofthe <br />l-atnr Code. for thc pcrfornrancc oflhe rvork for u,hich the permit is issucd. <br />lhavcandwillmaintsinworkcrs'@mpenstioninsurane,u requtedbyScctionlT00ofthet borCodc,forthcpcrformnccofthc <br />work for which this pcrmit is issued. My workers' compenslion insumncc cuicr and policy numbcr arc: <br />('arier: <br />I'olicy Numhcr:I:rlires <br />(This s(tion nccd not b€ complctcd if lhc pmit is for Onc hundrcd dollsE {$1001 or lcss) <br />_l ccnify that <br />beceme subjel I <br />in lhc pdfomancc of thc work for shich this pcmil is issucd, I shall not any pcnon in any manncr so as to <br />lo th. workers ' @mpenstion hws of Cslifornia.rl l subjst lo the workers' <br />compensation provisions ofSection 3700 ofthc hbor Codc. I shall comply <br />WARNINC: Frilure to seurc workers' comp.nsation is unlawful. and subjcct sn employcr to penaltics and civil <br />fin6 up lo onc hundrcd lhousand dolla6 ($100.000).io addition to thc cosl ofcompcnsation. damagcs c providcd for lhc Scction 3076 of <br />the t bor Code, interest and attorney's fees <br />LI('ENSED ('ONTRA("TORS DE(:LARA'I'ION <br />I hercby affirm under pcnnlty ofpcrjury thal I am liceNcd under pro|ision of('hapler I (cornnrencing \\,ith Seclion 7000) ofDiYisi('n 1 of <br />lhe llusiness rild I'rolcssions ('ode. and rnv license is in full lbrce and effect <br />Liccre Clrs:_ <br />Datc: <br />l-iccnsc Numbcr <br />Contractor: <br />CONSTRTI('TION LENDTNC ACENCY <br />I hercby allirm under penalty ofpcrjury thal thcre is a construction lcndinS agency for lhe pcrfomrance oflhc work for which this pcrmit is <br />issucd (Sa. -1097. Civ. C.). <br />l,ender's Name: <br />Lender's Address <br />APPLICAN'I"S DECLARA'I'ION <br />DenNlition Pcrilils-Asbeslos Nolilication Iederal Regulations ( l itlc 40. Part 6) <br />Required lf,llcr of Nolification <br />I ce(ify that thc fedcril regulations regarding asbcstos rcmoval arc not applicahle to this proiccl. <br />_ I cc(iry that I havc rcrd this is concct. I agrcc to comply with all City and County <br />ordinancG and Slatc lrws rclating to suthorizc reprGcnlativca ofthis City snd Counly to cnter upon lhc <br />rbovc mcntioncd propcny for inspetion <br />Applicant or ascnt sis -K <br />Permittcc namc (printl ____ <br />st6le <br />Date: <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 />POOUSPA <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 />Fina! Gas Test <br />Meter Release <br />t1 \,6 \ <br />FINAL A th 1v A}Q', <br />Notes, Remarks, Etc. <br />Forms\Plumbing-lnspector Racord.doc 03.31.06 <br />Datc: