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BING.!NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS oWNER RTIII,I)UR I)I.:I,('A RAI]ON <br />I hcrcby rll'irnr u[(lcr pcnxlty ol pc{ury lh{l I rill cxcmpt lil)ilr thc C{,rilrackns Liccnsc l-aw li)r Ihc li)lk)wing rcason (Scc.70Jl.5 <br />lJusincss aril l'rolcssiol Codc): Aily ('ity or Counly which rcquircs n lrrn]il lo construcl. altcr. inlprovc. dcnmlish or rcpair uny <br />slruclurc.priorl(,ils issuancc.ulsorcquircslhcalplicantlirrsuchprrnritlolilcasigDc(lslrtcnrcnt thrthcorshcisliccnscd fursunnl <br />Io lhc [)r)!i\irnrs ol'lhc Conlruck)r's l,iccnscd liw (Chaplcr 9. Connrcncing wilh Seclion 7(XX) ol l)ivishn .3 ol thc BusilNs\ xild <br />rpplicrnt li)r x prrmil suhjccls lhc xpplicrnl lo s civil pcnally of not trx)rc thun livc huil(lrc(l dollrrr (S5(Xl). <br />-1. <br />r\ (tr\rEr ol'lhc profEfly. or nry ctrrnl()ycc\ wilh wilqcs ils tl[ir s()lc conrl)cnsrti()rr. rvill rlo Ihc *ork and thc slmturc ii iot <br />lhc fftrrcilv wh() huilds or itrUovcs lhcru,n. rnd who docs such work hintsclfor hcrscll-or lh()ugh hi\ ()r hcr owrl cnlpk)ycc\. <br />salc). <br />-1. <br />as o{tcr ol lhc propcfly. !m cxclusivcly conlrncting with liccn{cd conlraclors lo conslrucl lhc projccl (Scc. 7044. Busincss <br />and lkrllxsir Codc: Thc Contract)r's Liccnsc l-aw docs nol npply k, rn owncr ofpropcrty who builds or improvcs lhcrcon. <br />and who conlracts for such projccls wilh ! Conlraclo(s) liccnrcd pursuunl lo thc Conlractor's l-icclsc lnw). <br />-lilillcxctrlDlUndcrsccli()n-.R,&P,C.lbrlhisrcason. <br />WORKERS' COMPENSATION <br />DECLARATION <br />I hcrcby alllrn undcr Jrcnalty of perjury onc oflhc ,bllowing dcclilrsti(trlsi <br />-l <br />havcandwill rminlainaCcrtilicrlco[Con*nlloSclf-lnsurcli)rworkcrs'compcnsatio[.as prolidcdforbySNlion.lTU)ofthc <br />hh)r CodL'. for thc lErformnce o[thc work for which the [Ermit is issucd. <br />-l <br />havc and will mainllin workcrs' compcnsfllion insuruncc. ds rcquircd by Scclion 3700 ofthc lakrr (irdc. for thc lErfortrlancc of <br />lhc work trtr wliEh this pcrmit is issucd. My workcrs' contpcnsfllion insurance cafiicr erd Fx)licy nunlbcr arc: <br />c,ricr, -\5e^ch,ra,tl< f,as6r6n-r Ce- Lw-ott'l <br />CSr 0 3 )[-----7 3/r 1>oPolicy <br />-l <br />ccnify that in lhc [Erformrce of thc work for which lhis pcrmil is issucd. I shall not cmploy any Jrcrson in any mmrcr <br />m as nr bccom subjert to thc workcrs' @mpcnsalion laws of California. Bnd agrce that if I slhuld hccom subjsl to tlr <br />workcrs' comltnsalion provisions of Scclion .1700 of lhe titnr Code. I shall. fonhwilh comply with thorc provisions.. <br />WARNINC: Failurc lo rccure workers' compcnsalion is unlilwful. and shall suhjcct an cilrplolcr lo qiminal pcnaltics rnd <br />civil fincs up to one hundred thoussnd dollars h thc cost as providcd lbr thc <br />I hercby sffrm undq [Enally of perjury that I am liensd under pmvision of Chaptc 9 (olrmrcing yilh Section 7000) of Division 3 <br />of the Busims and Prcfessions Code. ard my licens is in full forc 8rd eflect. <br />c3Liccnsc ,v,#*,, BA L( 6Llfi <br />Dale:_tcl Ltt <br />CONSTR.UCTTON LENDING AGENC:Y <br />I hcrcby aflirm under penalty of lrcrjury thrt th@ is I @nslrution lcnding agercy for thc perfomme of the work for which lhis pcmil b <br />hsed (SE. 3097, Civ. C.). <br />kndcr's Namc: <br />Lcnrlcr's Atldrcss: <br />APPLICANT NECLAN,A'NON <br />I hoebyaffmunder penalty of pcrjury ore of the followif,S dElestions: <br />Dcmlition Permils-Asbeslos Nolification Fcdcrsl Rcgulations (Titlc 40. PM6) <br />-Requircd <br />Lrtler of NolifEstbn <br />_l ccnify lhal lhe fcdcralreguloli(lns rcgsding asbcstos rcmovaltrc not opplicable to this prcjccl. <br />-l <br />ccrlily lh8t I havc rcad this applicati()n and slatc that thc ahovc inlornulion is conccl. I agrcc lo comply with all City and Counly <br />ordinances and State lxws rclating lo oflhis Cily and Counly to enter ufDn lhe <br />ahove rcnlioncd property for <br />ApplicaDt or Agenl <br />Pemrilee nsnro tY <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />lnterceptor/ 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 Pipinq <br />Fill Line/Back Flow <br />Pool HeateriGas 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 />FINAL 2111 20 WN)oz frf,\ <br />Notes, Remarks, Etc. <br />lz/tz//at - C//L -b*rrt <br />I 1t <br />n- lls9 <br />Dsle: <br />*,*-1,16-4t1