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PLUMBING.INSPECTOR RECORD <br />APPROVALS DATE ID/S!G.COMMENTS OWNI:R IIUII,DI:R I)I]I.('ARATIoN <br />llusirtcss antl Prolcssi()il Codc): Any Cily ()r Counly which rcquircs a Jtrnrit lo construct. altcr. iDlprovc, dcnrrlish or rcpair any <br />\lruclurc. ri(tr lo it\ i\(urncc. illso rcqilircs thc Apllicul lbr \uch Frmil k) lllc a signcd slillcrmnt thal hc or \hc is liccnscd pursuilnt <br />lo Ihc frovisi(,ns of llt Conlrilchr's Liccnscd l-uw (Chilplcr 9. Conrrcncing with Sccti(nr 7U[) ol l)ivision -] ol thc Busincs( a0d <br />ItolcssioilsCodc)orlhilthcorshcisexcnlpllhcrcfoilnn(lthcbasisli)rlhcrllcgc.lcxcirpli(n. ArvviohlionofSccti(ti70ll.5hynny <br />ilpplicxnlli)ral^-flnitsubjcclslhc applicrDlloacivilpcnrltyofft{nx)rclhrnlivchutr(lrcddollxrs(S5(X)). <br />-1. <br />ss owncr of lhc proFny. or my emplolres with wsgcs as their slc compensation. will do thc work md the stnrctre is not <br />intendc{ or offercd for slc (58.70{4. Busircss and Profcssions Code: The Contmctor's Liccns [!w dcs not apply to e owrer of <br />the pmFrty wlb huild.r or ir{reEs the@n. ard who dcs sh work himself or hcrslf or thrcugh his or hcr own employccs. <br />provided that such imprcvcmnts rc not inlcndcd or offercd for slc. lf. howcvcr. lhe buiHing or imprcvercnt is sld within onc )rtr <br />of corplctk n. thc Owrcr Builder will harc thc hrdcn of pmving thil he or shc di, mt boib or irpmw the prcFdy for the pu{ns of <br />slc). <br />-1. <br />ss owncr of the pmlErty. am exclusively contracling with liccnsd contracloF to conslruct tlE pmjst (Scc, 7044. Busircss <br />and ProfssionCodc:TheContraclor'sLicenseLawdoesnotapplyloanownerofprolrrtyw]nbuildsorimprovesthcreon. <br />and who contracts lbr such pmjects with a Contructo(s) licensed pursuant lo thc Contrsctor's Licensc Law). <br />I am cxemDt undcr Setion-. B. & P.C. lbr lhis rceson. <br />l)alr ()$r!(r <br />WORKERS' COilIPENSATION <br />DECI,AaAIION <br />I hercby alYirm under pnalty ofperjury ore ofthe following dcclarations: <br />l.rhr Crrlc. lirr thc pcrli)rilrrilcc ol lhc \r(,rk lirr *hich thc pcrnrit is issuctl. <br />_l have and Scction 3700 oflhe t{bor Code, for thc performncc of <br />lhe work carricr rnd Iplicy number m:(,,44 7,, <br />Policy -c3 t <br />-l <br />cenify lhat in the performnce of thc work for which this pcrmit is issucd. I shall not cmploy any pcrsn in any manrcr <br />s as lo hccom subjcct lo thc workcrs'comlEnsalion laws ofCalifornia. and agrce lhut if I should bccont subject to lhc <br />workcrs' compcnsrtion provisions of Seclion 3700 of thc Lsbor Codc. I shall. forthwith comply wilh thoE prcvisions.. <br />WARNING: Failurc lo scu,c workers' compcnsation ovemgc is aM shall subj(l an emplo;cr to aiminal Frcmlti{s and <br />civil fincs up lo orc hundred lhousmd dollars tI to thc cosl of corrlEnsation. damgcs as provided for the <br />Scction .l{ )?(r Llbor Codc. intcrcsl and <br />I hcrcby alnrm undcr pcnnlty ofpcrjury lhat I am liccnxd provision of Chapter 9 (coltmncing with Scction 70OO) of Division 3 <br />of lhc llusiilcss and Profcssions Codc. and nty liccnsc is in lull firrcc and cffcct. <br />,,^ <br />l-iccnsc C3 <br />[rsle:_ <br />I hercby aflirm undcr pnalty of Frjury lhat there is a @nrtruclhn lcnding agcncy for thc fErfotmrce of rhe work for which this Jrmit is <br />issucd (Scc. 309?. Civ. C.). <br />kndcr's Namc: <br />bndcr's Addrcss: <br />APPLICAN'I' DECLARATION <br />I hcr+,y {llim undcr pcnalty ol pcrjury onc oI thc i,llowing dcclarat ions: <br />Dcnx)lili()n Pcrilrits-Ashcsk)s Notificali()n Fcdcral Rcgulutiots (Tillc 40. Ptn6) <br />-Rcquircd <br />l-citcr ol Notilicatior <br />-l <br />ccrlify lhsl lhc fcderal regulations rc8trdin8 asbcslos rcrnovalarc not opplicablc to this nrojet <br />_l c(atify thal I have rcad this application ald slate thul thc above infomion is corect. I <br />ordinanccs and Statc [aws rclaling lo huilding <br />stx)vc menlioncd propefly for <br />,\ppli(nnt r)r AgeDl <br />Pemite name <br />UNDEH GROUND <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 Pipinq <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rouqh 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 />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewer/Cap <br />Back Flow Device <br />Rouqh Plumbinq <br />Final Gas Test <br />Meter Release I <br />F!NAL ').rq '1,O {-fr67 <br />Noteq, Rema;ks, Etc <br />tLl b/t/r4 ,-flrL 6?- *?7 <br />I I l. <br />l)alc: <br /><?v? <br />Do*: <br />L</ <br />Drftl <br />-DtW