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r- . -Jil/IBING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hereby sffirm undcr lEnalty of pcrjury lhal I m cxempl frcm lhe ContmcloE' Liccn* kw for the following reawn (Sec.?031.5 <br />Busincss and Profession Code): Any Cily or County which requires a grmit to construcl, alta, improve, demlish or rcpair any <br />slructurc. prior to its issuance. also rcquircs lhc applicant for such lEmil lo filc s signed statercnt that he or sh€ is liccnrcd pursmt <br />b the Fovisions of lJrc Contractor's Liccnsed taw (Chaplcr 9. Commcncing wilh S$tion 7000 of Division 3 of the Busincss ond <br />Prcfessions Codc) or thal he or shc is cxcmpt thcrefiom Bnd lhc basis for thc allcgcd exemption. Ary violation of Sction 703 I .5 by any <br />spplicsnl for s pemil subjccts lhc trpplicanl lo a civil pcnalty of not mre lhan fivc hundred dolles ($50O). <br />-1. <br />as owrcr of the prcpny. or my emplo)es with wsges as thcir slc compenstion. willdo the wrk ard thc strutw is rct <br />interded oroffcrcdforsh(56.T044.BusinessandPrcfessionsCode:TheContractor'sLicen$kwdoesnotapplyloEnownerof <br />thepmFrty whobuildsorinpmvsthe@ea.dwhodcsswhworkhimsclforhcrslforthmughhisorherowncmployes. <br />providcd that such imprcvemnls m not intendcd oroffcrcd for slc. lf. howevci thc buiHing or inqrrcvetrent is sld within onc )rs <br />ofcomphlion. the Owrer Buiklcf will hare tlrc hurden ofprcving lhal hc or she dil mr huih or ir{row tlrc pmJE ly for thc puryns of <br />sle). <br />_1. {s owncr of the preFny. am cxclusivcly conlracling wilh liccnscd contracloN to con$rucl the prcFct (Ss. 7(X4. Business <br />and ProfssionCodc:ThcContractor'sLiccnscLawdoesnolapplytoanowncrofpropefrywhobuildsorimprovcsthcreon. <br />and who conlmcts for such pmj$ts with a Conlmclor(s) licensd pumuanl to lhe Conlraclor's Liccns [rw). <br />WORKERS' COI\IPI'NSA'II(IN <br />DECLARA'I]0N <br />I hercby affirm undcr penalty of perjury ore of lhe following dcclarations: <br />-lhavcondwill <br />roinlainaCenilEateofConrcnlloSelf-lnsureforworkcs'compenution.as prcvidedforbySNtion3T00ofthc <br />Latnr Codc. for thc pcrformancc ofthc work for which lhe pcrmil is issucd. <br />-lhnvcBndwillmainlrinworkers'conrpcnsutioninsurance.as <br />rcquircdhyScction3TU)oftheLahorCode.forlhcpcrforronccof <br />lhc work for this pcrmit is issucd. My workers'ion insurance canicr and numhcr &c: <br />u v//t/>o <br />Policy Nu -Csr 6>3 <br />-l <br />ccnify lhat in thc lErforrmncc of lhc work for which lhis pcrmil is issued. I shall not employ any pcrson in any manner <br />s as to bccom subjccl to lhc workss'@mpcnsation laws ofcqlifornia. and agrcc thal ifl should bccom subjc{t to thc <br />workss'compcnsalionprovisionsofScclion.lT0OofthehtnrCodc,lshall.fonhwithcomplywiththosprcvisions.. <br />WARNING: Failurc to scurc workers' compcnsalion r is unhwlul. and shrll suhjccl an cnrploycr lo ffinrinal Fnahics and <br />oddilion lo lhc cost of compcnsatbn. damgcs !s providcd for thccivil fines up to onc hundrcd thousand dollus ($l ). in <br />Srclion 30?6 of thc kbor Code intercst <br />o,,", vll/?>l7 <br />and <br />/, <br />I hcrcby affirm undcr pcnslty of pcrjury lhsl I am licensd provision of ChBpts 9 (comrencing with Scction 7(n0) of Division 3 <br />of thc Eusiress and Prcfcssions Codc. ard my licensc is in full fors ard effst.3 6Liccnsc <br />Dsle:_lt />-/? <br />I hcrchy affirrn under Jrcnahy of pcrjury lhst Ihcrc ir a construclion lcnding agcncy for lhc pcrf(rnmncc oflhc work for which this Frmit is <br />issued (Ss. 3097. Civ. C.). <br />kndcr's Namc: <br />kndcr's Addrcss: <br />APPLICAN'T DECLARATION <br />I frrutry aflirnr undcr pnalty of pcrjury onc of thc follo* ing dmlaratirrns: <br />l)cDr)lilir)n Pcrnrits Asbcslos Nolillcation Fcdcr{l Rcguhtiotrs ('l itlc 40. t rrt6) <br />-Rcquircd <br />llltcr (,f Notiflcation <br />_l ccnify that the fcdcral regulations rcgaJding asbcstos rcmov0larc not 0pplicable to this projfft. <br />-l <br />ccniti that I havc rcad this appli <br />ordinarccs und Slate laws rclutinS lo <br />ication and strlc thnt thc ahrvc informltitrn is corect. I agrcc to conrply <br />ives ofthis Cily <br />wilh allCilyand Counly <br />hcrcby aulhorizc rcprescnlat and Counly to enler ulnn lhe <br />obove mnliored pmfrcny for V t ^," ///>dt?Applicenl or Agent <br />Pcmilee nanre f-L L.c- <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />I nterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rouqh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />Main Drain/Pool Pipinq <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewer/Cap <br />Back Flow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Belease I <br />F!NAL 7l$Vo DrtnOrt *81 <br />Notes, Remarks, Etc.rI <br />-l <br />m crcmpt undo S8tion- B. & P.C. for this lwn. <br />Dsl._ Ow