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PLUMBING-!NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I h6cby affm unda pmalty of pcrjury that I m exmpt frcm thc ContractoE' Licre kw for lhc following r@n (Ss.7031.5 <br />Buin6s ed Profsion Cod.)r Any Cily or County rvhich requirB a pqmit to construct. altq, im!trovq dmolish or rcpair any <br />slructuc, prior to its isumcc. also rcquirc the Eplicmt for such pemit to 6le a signcd statmmt that hc or shc b lic@rcd pwumt <br />io thc Frovisiom of lhc Contmclor's Liccn*d Larv (Chapl6 9. Commocing rvith Sstion 7000 of Division 3 of thc Buine ud <br />ProfcssionsCodc)orthatheorshciscxcmptthqcliomedthcbsisfortheallegedcxcmpion. AnyviolationofscctionT0-1l.5byany <br />applicant for a pmit subj(ts thc applicsnl to a civil poalty of not morc the five hundrcd dollus ($500). <br />-1, <br />I oMq of thc fopcdy, or my mployc with wag6 I thcir solc compcroation, will do thc work ed thc struclw is trot <br />intqdod or oFcrcd for ele (56.7044, Bwins ud hofsions Codc: Thc Contraclor's Licoc law doc not apply to u omr of <br />the propsty who builds or improve tluarr Ed who do6 such rcrt hiroelf or hwlf or thrcugh his or ho ow mploye. <br />providcdthstsuch improlqrcl$erctintodcdorolfqcdforslc. lf.howdc,thctuiHingorirnprcvcrcntisrcHwithinonc]qr <br />ofcompk iotr thc Orra Buikb will havc tlrc hudo ofFoving thd hc or shc did not build or imprcvc thc prcpcty for thc prrpos of <br />sh). <br />l. as o$rro ofthe propoty. au crclusively conlracling $'ith liccils.ai conlracloE k) consrnrct the proisl (Se. 7044. Busirres <br />and I'nrfsion('ode:-[heConlraclor'sl-icensel-awdocsnolapplyloano\rnerofproperly\!'hobuildsorimprovesthercon. <br />and \vho contracls for such proie(ls lvilh a Contracto(s) licensed pulsuant lo the Contract(rr's License l-arv). <br />I am cxen)pl undq Selion . Ii. & P.('. for this rcason. <br />()N ner: <br />WORKERS' COIIPENSATION <br />DECI.ABAIIAN <br />I hacby rffm undc poultyof pojury onc of the following dcluatiorc: <br />I halc ancl s'ill ntaintain a ('cnilicale ofConsenl to Self-lilsurc fol srrrktrs conrpensation. as proriricd for by SGtion 1700 ofthc <br />l,atxrr('odc.forlhepo'fornranceofthc\rorkfor$]lichlhepornilisissucd. <br />I hnve and will maintain workers'Strtion 3700 of lhc kbor Codc. for thc pcfomocc of <br />the rvork for which this pmit is cmiq md policy numbs [e:t Car -^\rClr <br />Policy <br />. wrt/Ao <br />- <br />I cenify (hal in lhe psfomancc of the work for which this pomit is issued. I shall not mploy any poson in any mmn( <br />I 6 to bccomc subject to thc work6' compensation laws of Califomia. and agre that if I should bacome subjcct lo thc <br />workss'compansalionprovisionsofScction3T00ofthelrborCodqlshall.forthwithcomplywiththospmvisioN.. <br />WARNING: Failure to scurc workm'compmsation coverage is tularvful. and shall subjet an mployo to oirninal psultie md <br />civil hnes up to one hundred thouund dollare ($100,000), in addition to the cost of compcnsation. dmags 6 provided for the <br />Sqtion -1076 of thc t bor Codc. irt66t and attoB's fG. <br />x/AD <br />DECT.,1RA ION <br />I hctcby alfirrn under pmally of ptrjury lhat I am licensc<l untler prr)\ ision ofChaptft 9 (commencing s'ith Sction 7000) of Dit'ision l <br />of thc llusincss md Prclssions Code. md rny licose is in full forcc md effect. <br />4 \ot'15\&Liccnsc <br />Drte: <br />Number: <br />-l/5/Po"ro <br />CONS'I'RU('I'ION I,ENDINC ACEN('I' <br />I hcteby aflirrn under penall! o f per iur)' lhat thse is a conslructi()n lcncling agmcy- for the pcfonnancc of lhe rsork for s hich this pcrnit is <br />issucd (Sec. 3097. Civ. C.). <br />lrnds s Namel <br />l,ender's Address: __ _ <br />APPLICANT D3:CLARA'I'ION <br />I hottyaflim undo pmalty ofper.jury one ofthe follos'ing delarations: <br />t)ern<rlition Pqmits-Asbestos Notification Fedsal Regulations (-l irle 40. Pan6) <br />Requied Lel(s of Nolifi cation <br />with all City and County <br />ild County to mls u[nn the <br />above molioned propdy for <br />Appllcrnt or Agetrt <br />Permlle name <br />*,..91 t//t>N <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Building Sewer <br />Area/Storm Drain <br />I nterceptor/ Clarifier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rough 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 />Fina! Gas Test <br />Meter Release <br />FINAL <br />Notes Remarks Etc. <br />e.. c. tII Ltrzrhtl,r-V tttz ,,r/r -/ r^ I rad,]ta dztLat <br />Cmis <br />I