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PLUMB!NG.!NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS (IWNDR IlUlt,l)tlR l)EI,CARATION <br />I hcrchy affirm undcr lEnxllv ol F{ury thot I rN crcrrln liom thc Conlrack)rs l-iccn\c Las' for rhc following rca{[ {Scc.70-]1.5 <br />Busincss utl P(rttssion C(xlc): Any Cily or Counly which rc<luircs a lrcrnrit k) con\truct. tllcr. improvc. denx)lish or rcpat tny <br />slnrclurc.priork)ils i\\uancc.al\orcquircsthcilpnlicrntli)rsuchl*rmitt()lilcrsigncdstntenrnt lhxthcorshcisliccnscd pursutnl <br />Prolcssi('n\(i)dc)()rlhillhcorshciscxcfilpllhcrcfronrrndthchrsisli)rlhcallcgcdcxcnrilion. AnyviolathnofScclionT0ll.5byany <br />upplicalllirapermilsuhjcctsthc applicrDlhacivilpcntltyofilotnr)rclhailllvchundrcddollars(S5(X)). <br />-1. <br />as owncr oflhc profEny. or my cmployes with wagcs as thcir slc mmpcnsation. will do the work and thc structrc Ls mt <br />intcndcd oroffercdforsh(5(.?044,BusiressandProfessionsCodc:ThcConlraclor'sLicensclrwdmsnotapplyloanowncrof <br />the pmfEny who builds or imlreres thcNn. and who dfts such work himsclf or hcrself or through his or hcr own employccs. <br />provided lhal such imfmwmnts rc ml irtcrded orotlercd for sle. lf. howcvs. the huilding or inprovercnl is sld within ore )a{ <br />ofcomplclion. lhe Owncr Builder will have thc burdcn of proving that hc or shc dil not buiH or imprcvc rhc pmFf,ny for the purFr$ of <br />slc). <br />-1. <br />as osrcr of lhc pmJrcrty. 8m erclusivcly conlracling wilh liccnsd contraclors lo @nstrucI the pmFct (Ss. 7044, Busiress <br />and Pmfxsion Code: Thc Conlractor's Licensc Lsw d@s nol apply to an owncr of 1ro1rcrly who builds or improvcs thcreon. <br />and who contmcts for such pmjccls with a Contnclor(s) licenscd pursuant to the Contractor's Liccnse hw). <br />_l am cxcillil undcr Scctk)n_. B. & P.C. lirr this rcas(,n. <br />Dste:_Owner:_ <br />WORKERS' COIIPENSATION <br />DECLARATI(TN <br />I hercby alfirm undcr pcnalty ofperjury onc ofthc following dcclffatbns: <br />Lalxrr (ixlc. lor lhc Frlirrnrancc ol thc uork lirr uhich thc pcrrrit is issucrl <br />-l <br />havc and will maintain workers' comJrcnsalion insurarcc. as required by Section 3700 of the kbor Codc. for thc pqrformrce of <br />lhc work is issuql. My workers' comlEnsalion insurance cmier and [mlicy numbcr trc: <br />Policy \ttzq <br />-l <br />cenify lhal in lhc pcrforrorcc of lhc work for which lhis pcrmit is issued. I shall nol employ any person in any mtrnncr <br />m as lo bccorc subject h thc workers' comJrcnsation laws ofCalifornia. and agrcc that if I should bccom subjeEl to thc <br />workcrs' compcnsalion provisions of Section 17il) of lhc L{tnr Codc. I shull. forthwith comply with lhose provisions.. <br />I{ARNING: Failurc to surc workers'compcnstion covcmge is unlawful. and shall subjcct an cmploycr to diminal lEnaltbs snd <br />civil fincs up to onc hundred lhousnnd dollars ($1m.000).uddilion b thc cost of darogcs ar provided for lhe <br />Sdion 3076 Code.ard sttomy's <br />( <br />of lhc llusincss antl Pr()lc\si()ns Codc. an(l nrv liccnsc is in lult li)rcc and clltcl <br />) <br />Liccnsc 3 c <br />-1((q <br />CONSI'RUCTION LENDING AGENCY <br />I hcrcby rlllrrn uildcr pcnrlly of pcrjury thrt thcrc ir a constructi(trr lcnding rgcncy lbr thc Jrcrfornuncc of thc work for which this lErnlil is <br />issucd (Scc. .1097. Civ. C. ). <br />Lcndcr's Nlnrc. <br />krder's Addrcss: <br />ITPPLICiINT IIECI ARATION <br />I lrrt'hv aliirm undcr pc[illly ol'pcrjury (,ne of thc lblk)q'ing dcclxrrl i(n\: <br />Dcilx)lilion PcrDrils-Asbcstos Nolillcation I;cdcrrl Rcgulati(ns ('l itlc 40. I'art6) <br />_Rcquirc(l [.cllcr ol Notillcati(nl <br />_l ccrtify lhst thc fcderal rcgulstions rcgarding asbcstos rcmval arc not applhable to this ppFct. <br />-l <br />cslify lhal I havc rcad this application snd stslc thal the atnvc informalion is corBl. I agr@ to comply with all City and Counry <br />ordiranccs und Stalc Lilws rcloling k) <br />above mntiorcd pmpef,y for <br />Applicant or Ageol <br />Itemritee nsme <br />rcpresentstivcs <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildino Sewer <br />Area/Storm Drain <br />lnterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Pipino <br />Roof Drain <br />Tub/Shower Test <br />Rouoh 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 Plumbinq <br />Final Gas Test <br />Meter Release t <br />FINAL Z \417r)b ft/rn f,-* Fv <br />Notes, Rerparks, Etc. <br />l?-trl pt - cl rz I ) ftlD,,1 *'f7 <br />t t, <br />Dale:_ <br />ll