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DATE ID/SIG.COMMENTSAPPROVALS <br />UNDER GHOUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />I nterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rouoh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />lVlain 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 <br />Rouqh Plumbing 9//t ,kq-w \tE;v {d <br />Final Gas Test <br />Meter Release .v S*4r)FINAL 4 '-02-17 s a-r.g I <br />Notes, Remarks, Etc <br />.J <br />l tl't,i'rj:i,1:',fil ffiIiT"'t:iijm':: ll ili:,:lr:TrJilr :J:il <br />xpt)licrnllirrilpcril)il\uhjccl\lhc xppli.rnlkixcirilpcnallv()ln()lilx)rclhrilli\chun(lrcddolltrs{55(X)). <br />sillc). <br />antl who e()trlract\ li)r such ptrriccls with il (i)rlrilclo(s) liccilscd pur\ur0l lo lhc Corxrirck)r's Liccnsc Lilw). <br />I rrr rxr:rnDt rrklur Sc.lx)o . Il. & l'.('. li,r lhis rur\on. <br />Dale:-Owner:_ <br />WORKERS' COMPENSATION <br />DECI ARATION <br />I hcrcby allirm undcr tEnahy of pcrjury ooc of thc following dccltrations: <br />_l havcundwill MintuinrCcrtilicatcofConscnttoSelf-lnsurcti)rworkcrs'cotrrpcnsalion,as providcdl(,rbyScction3T0ooflhc <br />L{tx}r Gxlc. for thc pcrlbrnuncc oflhc work frrr which thc pcrntit is issucd. <br />_l have and will mnirtdin sorkcrs' conrrcnsation in{urancc. as rcquircd by scclion 37(D of thc lrhor G)dc. for lhc 1^-rlirrmncc ol <br />thc work for which this pcrmit is issucd. My workcrs' compcnsalion irsurancc canicr and lnlicy numhcr uc: <br />i <br />t oe <br />Policy <br />_l cenify that in the pcrformncc of thc work for which this permit is issued. I shall not employ any person in any manncr <br />s &s to tEom subj.rt to thc workcB' cor{Enslion laws of Colifomia. and agrc thal if I should bccom subject to thc <br />workers' compcnsation provisions of S€ction -1700 of the Latnr Codc. I shall. fonhwith comply with lho* prcvisions.. <br />WARNING: Failurc lo surc workers'comfcnsalion covcEgc is unlawful. and shall subject an cmploycr to oimiml pmlties and <br />civil fincs up to one hundrcd thousand dollam ($1ffi.000). in <br />Seclion 3076 of lhe kbor Codc. inlercst ond atlomy's fecs. <br />addition to thc cost of providcd for thc <br />Applicunt:-X <br />I hcrcby affrm under pemlty of perjury thrr I m liansd under provision of Chaptq 9 (commrcing with Secrion 7000) of Division 3 <br />of th€ Business ed Profcssions Code, ard my license is in full fore and cffect. <br />Nunrbcr:44ltt <br />UI u ( <br />W <br />I hcrcby uflirm undcr Fnally of Frjury that lhcre is a construclkln lcnding 0gcncy lbr lhc pcrfoilmncc of thc work for which lhis fErmil is <br />issucd (Scc. 3097. Civ. C.). <br />[fndcr's Namc: <br />[*ndcr's Addrcss: <br />APIIJI;ANLDECI.AEAIIQN <br />I hcrcby aflim !ndcr pcnally of pcrjury onc of thc followinS dcchrations: <br />Dcrfi)lilir)n Pcrmits-Asbcslos Notificolion Fcdcral Rcgulalions ('I itlc 4t), Pan6) <br />Rcouircd [Iltcr ol Noliticalhn <br />_l ccnify that thc fcdcrsl rcgulnlions rcguding asbcstos rcn$vrlarc not applic0hlc lo lhis prrjccl.ol-- Ll ccf,ify that I havc ,cad rhis application ard stalc lhat thc ahovc information is corccl. I agre to comply with all City and County <br />ordinanccs and Slatc Lilws relaling lo building construction. and hcrcby authorize rcprcscntalives ofthis City and Counly to cntcr ufnn the <br />stnve mntiored pmpcny for <br />llrrtr ' !'lApplicunt or Agenl <br />PLUMBING.INSPECTOR RECORD <br />\rl)xtr: ' <br />Pemllee name (printt: (.