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PLUM BING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS Omer-Buildcr Declaration <br />I hcreby aflirm unda pcmhy of pc.jury thEt I rm qcmpt form the Contractors' Liem taw for thc following r6on (w.7031.5 Bulin6s <br />and Profesion Codc): Atry City or County which rcquiro r permh to @Ntruct, 8her, improvc, dcmolish or rcpair aoy rtrucrue, prior to iB <br />issune,alsorc4uircthcsppliqntforsuchpcrmittofilcEliBDcdstrtcmcil thrtheorrhcisliccrocd pursuurtotheprovisiorcofthc <br />ContEctor's Li@Ncd hw (Chlpter 9, ComcnchS wiih S*riotr 7000 of Division 3 of thc Buinas ud ProfqrioN Codc) or thst hc or <br />shc is qempt thac&om and thc basic for thc lllcgcd .xcmption .Any violation of Saion 7031.5 by any appliont for ! pGmit tubjccts thc <br />appliont to a civil pcn!lty of not morc thrn fivc hundrcd dollars ($500). <br />-1, <br />rs omer of thc propcny, or my cmploya whh mgc as thcl solc @mpcNEtioq will do thc work ud thc structuc is not iotctrdcd <br />or offercd for ule ( Ss.7044, Busirc! ud Profqsionr Codc: Thc Conrsctor's Liccm. Llw doq not rpply to e omcr of the prop€rty <br />vho builds or improvG thcreon, ud who dos such work himselfor hcrrclfor tluough hie or her om cmployc, providcd that such <br />improvements uc not intcndcd or ollcrcd for sle. lf, howcvq, th€ building or improwment is sold within onc ya of omplerioq thc <br />Omcr-Builda will have the burdcn of proving that he or shc not build or improve for tha purposc ofnlc). <br />_1, a oM* of thc propcny, am dclusivcly contractiog with lieEcd contractoG to @Btruct rhc projcct ( 56. 7044, Buin6s ud <br />Profc$ion Codc: Thc Cotrtn6r'3 LieBc hw do6 not rpply to m oMcr of p.opqty who builds or improve thqon , aad who <br />@nt!8ct! for such projct! with ! Contnctor(!) liccnscd purlunt to thc Contndor's Li@nsc law.). <br />_l rm cxempt utrder S6tion <br />Datc: <br />& P.C. for this r6on <br />WORKERS COMPENSATION DECLARAI'ION <br />I hereby alTirm under penalty ofperjury one ofthe following declarations: <br />_l havc and will mainbin . Cenifiote of CoNcnt to SelfJNu,e for workets' @mpcNation, as provided for by Setion 3?c ) of Ihc <br />Iibor Code, for thc performance ofthe work for which the permit is issued. <br />_I heve and will roinlrin workcrs'@mpcMtion irounne, u rcquircd by Secrion 3700 of the Labor Codc, for thc pcrforure of thq <br />My workcri' @mpcn$tion inlume orrier and policy numbcr uc:work for which this is issued I <br />Carricr: <br />(This section need not be completed ifthc permit is for One hundred dollars {$l0O) or less) ' , <br />_l cenify that in thc performncc of the work for which this permit is issued, I shall not cmploy any person in any manner so as to <br />became subjot to the workers ' @mpensation laws ofCalifornia, and agree thst ifl should become subject to thc workers' <br />compenstion provisions ofSection 3700 ofthe hbor Code, I shall, forthwith comply with those provisions.. <br />WARNING: Failurc to seurc worhcrs' <br />fine up to one hundred thousnd dolhrs <br />@mpeNrtioo @vqsge is unlawful, <br />(S100,000),in sddition to the cost of <br />.od lhall lubjed.n cmploya to oiminal pcmltiq and civil <br />@mpcnstion, drroges u provided for thc S@tion 3076 of <br />the Labor Code, interst snd attorney's fces. <br />LICENSED CONTRACTORS DECLARATION <br />t heeby aflirm undcr pcmlry ofpcrjury thar I sm liccnlcd undq provilion ofChspter 9 (ommcncing with Scaion 7000) ofDivirion 3 of <br />the Businss and Profosioro Code, rnd my liccroe is in full fore md clfct <br />Lieroc <br />Drte:'2,/sh2-Contractor <br />-T CONSTRUCTION LENDINC AGENCY <br />I hereby aflirm undcr pemlty ofperjury that there is a coNtruction lending aSrncy for the performnce ofthe work for which this permit is <br />issued (Ss 3097, Civ C ) <br />Lendcr's Name: <br />Lender's Address <br />APPLICANT'S DECLARATTON <br />Demolition Psmitr-Asbcatos Notifiotion FeicrEl Reguhtions (Title 40, Part 6) <br />_ Rcquled Lctta ofNotifiotion <br />_l ccnify that thc federal rcgulations regarding ubotos removalsrc not sppliqble to this projct <br />_ I ccniry thit I hlve rad thir appliotion md rtlte tlat thc rbove information is concd. I agr€ to @mply with all City rnd County <br />ordimncq and Statc I*ws rclating to building coGtructior\ and h?reby authorizc reprB.ntrtivci ofthis City snd CouDty to entcr upon the <br />rbove mcntioncd propcny for irupcction pupo!6. <br />Appliont or rgcnt rig.: <br />Pamitte mmc (prht): <br />UNDER GROUND <br />Waste & Vent <br />Water-Underfloor <br />Gas-Underfloor <br />Building Sewer <br />Area/Storm Drain <br />I nterceptor/ C larifier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Pipeing <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 \Ir{I lll,^/ <br />Final Gas Test l .l <br />Meter Release <br />t I I <br />FINAL 1 /7h,/,l ,/Notes, Remarks, Etc. <br />,*, zfi/lz 4priun, Luca. L / Ur <br />-- r.icense Number as*ce-- <br />-o^," 44y'2 <br />l1