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PLUMBING.INSPECTOR RECORD <br />APPROVALS DATE !D/SIG COMMENTS owNl.lR Ilull.])t:R Dt]t,( ARATtoN <br />I hcrchy nfllnn undcr pcfilly of pcrjury lhat I anr cxcnul from lhc Conlrnclors' l-iccn\c l.aw for rhc folk)s,ing rcavrn (Scc.7{).11.5 <br />Ilusincss nild Protcssbn (ixlc): Any City or Counly which rcquirc\ a Frnril to con\lruct. altcr. inlprovc. dcmrlish or rcpair any <br />structurc.priorloits iss[lncc.ulsorcquircslhcapplicxtrlli)rsuchEmrilk)filca$igncdstotcrncnt thathc()rshcisliccnscd pursuant <br />l(, thc provisions ol'llrc C(,nlrilclor's l,iccnscd Lnw (Chaplcr 9. (i)trrnrncin8 wilh Scclion 7(X[ of Divistrn J of thc Busincss and <br />I'rol'c\\ionsCodc)orthathcor\hciscxcnrilthcrclionrilndlhcbasi\li)rlhcrllcScdcxcnrplion. AnyviolationofSccti)n70-ll.5byany <br />applicunlli)rrpcrDril\uhjccl\thc applicanttoacivilpcnxltyolnottr()rctlranl'ilchundrcddolhrs(S5(X)). <br />-1. <br />as owncr of thc Im[Eny, or my cmployccs wilh wages as their solc compcnsation. will do lhe work and the stnrctue is mt <br />inlerded or offercd for slc (SN.7044, Busimss and hofessions Codc: The Conlrnclor's Liccn$ lnw docs not apply to an owrer of <br />lhcprcIErly wlhbuildsorirpmvcsthcErn.srdwhodmssuchworkhimselforhcriclforthrcughhisorherownemployccs. <br />providcd thBt such impmvcrcnts re nol inlcndcd oroffercd for sle. If. howcvcr. lhc truilding or impmvemnt is sld wilhin onc ycil <br />of cotrq,lction. lhe Owrer BuiHs will have the butden of pmving thal hc or shc dil mt huild or ir{,mve the pmprty for the puqnsof <br />sk). <br />-1. <br />rs o*ncr of lhc prcpcny. anr cxclusivcly conlraclinS with liccnscd conlrack)rs k) conslnrct thc projcct (Scc. 7044. Busincss <br />!il Pr)f6\i)nCodc:'l'hcConlraclor'sLiccnscLawdocsnotapplytoanoqncrolpropcrtywhobuildsorimprovcsthcrcon. <br />and who conlracts for such projccls wilh a Cortlraclor(s) liccnscd pursuflnl k) lhc ('onlrack)r's Liccnsc ljw)- <br />_l am cxcnul undcr Scclion_. B. & P.C. lbr lhis rcason. <br />lhle: <br />W(IRI(FRS' COIITPENSATION <br />DECLARATION <br />I hcrchy ofllrmunder penalty of pcrjuryonc of thc following declarations: <br />l.alxr Crxlc. li)r lhc pcrlornunce ol lhc s()rk ti)r which lhc ncurit i\ is\ucd. <br />-l <br />havc and will roinlain Sstion 3700 of thc Labor Codc. for (he perfomncc of <br />lhc \rI)rk lhi\carrct ard Jrrlt,icy numhcr uc: <br />I\)licy / ts'r-to f q\t 2 {1,n" <br />-l <br />cenify (hal in thc pcrformncc of lhc work for which lhis pcrmit is issucd. I shall not employ any lrcnon in any manncr <br />so as lo hccom subjcct lo the workers' compcnsntion lows of California. and agrcc Ihat if I sk)uld bccom subject lo thc <br />workss' compcnsation provisions ofScction 3700 ofthc Lutrr Codc. I shall. forlhwith comply with lhose previsions.. <br />I{ARNING: Failure to rccure workcrs'compcnrlion svcmgc is unlawful, ud shall subjcct an cmployer to oiminal Imahics and <br />civil fincs up to onc hundred thousand dollars (S100.fix)). in lhc cosl of damges as providcd for lhc <br />and lccs. <br />I hcrcby amrm undcr Fn{lty ofperjlry thar I am provision of ChBpls 9 (comrencing with Ssthn 7fi)O) of Division 3 <br />of lhc Busircss snd Pmfessiohs Code. and my lhcns is in full fore ard eff$l. <br />1 6Liccnsc <br />I herchy sffrm undet Fnalty of lE.jury lhal thrc is a conslructhn bnding agercy for the [Erfomrce of the work for which lhis txmil is <br />issued (Se. 3097. Civ. C.). <br />Lcnder's Namc: <br />knder's Address: <br />APPLICAN'I' DDCLARA'I'I(IN <br />I hcruhy allirill undcr pcnally oI pcrjury onc of lhc lblhwing dcclrrationsl <br />l)cmolitbn Pcrnrits Ashcstos Notificati(rn Fcdcral RcSulrtions ('l itlc .lO. Pxn6) <br />-Rcquircd <br />lf,llcr of Notificultnr <br />-l <br />ccrlify that the fcdcral rcgulations rcgording asbcstos rcmoval are not applicablc lo this prcFct. <br />_l ccrlify thal I hdvc read this application sod state lhat lhe atnve inforrotion is cotrcct. I agra to comply wilh all Cily and County <br />ordinanccs and Stalc lrws rchling to <br />stnvc mntioNd prcIEny for <br />Applicunt or Agenl <br />Pemtilce nrme <br />{trd ';ry"-'#;i"r;l; <br />UNDER 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 Pipino <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 />Rough Plumbing <br />Final Gas Test <br />Meter Release <br />F!NAL L rq -zo t &r\0 t L.l*{-t <br />Notes, flemarks, Ftc.TT <br />tzll?/n- dlr- Yfr ry <br />I <br />Owtrer:_ <br />Dsle:t <br />Date: <br />0U6L * <br />,