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PLUMBING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby afftrm undcr Frcnally of perjury that I m erempt fmm thc Contractos' Licens Law for lhe fotlowirg rc&sn (Scc.7031.5 <br />Busincss and Profcssion Codc): Any City or County which reqlires s pcrmil lo conslruct. alts, imprcvc. dcmlish or rcpqir oy <br />struclw. prior to its issumc, also rcquircs thc rpplicent for such lEmit to fik a siSned statcrcnt lhat he or sh€ is liccnred pmuant <br />to the prcvisioN of thc Contretor's Licensd law (Chaprer 9. Commercing wilh Section 7000 of Division 3 of thc Busiress and <br />PmfcssionsCodc)orlhathcorsheiscxempllhercfromandthchasisfortheallcgcdexcErption. AnyviolstionofsctionT03l.5byany <br />appticant for a pcrmil subj$ls tha spplicsnt to 8 civil pen.liy of nol rurc lhan fivc hundrcd dolles ($50O). <br />-1. <br />as owncr of lhc prcpny. or my employees wilh wagcs as thcir mlc compcnsation. will do lhc w6k ed thc stMtw is ml <br />intendcd or offcrcd for sh (Se.7(X4. Business and Profcssions Codc: Thc Contraclor's Lkcnse llw does mt .pply to an owrcr of <br />lhe preFny who huilds or ifilpmres the@n. and who d@s $ch work himsclf or hcrsclf or thrcugh his or her own cmployces. <br />providcd that such improwrcnls m mt intended orofferc{ for sb. If, lxrwcvcr. th. building or itrqrreremnt is sH within onc Ftr <br />ofcomphlion. thc Owncr Builder will hare the burdcn of pmving that hc or shc dll mt buiH or ir{,rcve the prcFrty for thc purps of <br />salc). <br />_1. ns owncr of lhe pmpcny. anr cxclusively contracting with liccnscd contraclom to construct the pmjcct (Sec. 7O44. Busircss <br />and PmfssionCodc:ThcContractor'sLicenscLawdocsnot0pplyloanowncrofpropertywhobuildsorimprovcsthereon, <br />and who conlmdsforsuchpmFctswithaContraclor(s)liccnscdpursuantlolheContractor'sLicenw[jw), <br />-l <br />smeremDt under Setion-. B. & P.C. for this re&son. <br />()$ner <br />IY!}EBESLCQDIPINSAIION <br />DECI,AEAII!]N <br />I hcreby affirm undcr pcnalty oflqjury ore ofthc following dcclarations: <br />-lhavcardwill <br />mintainaCcnifrcateofConsnttoSclf-lnsurcforworkers'compensalion.as prcvidcdforbyScction3T00ofthe <br />tabor Codc. for thc performrce of the work for which thc permil is issucd. <br />/hou"und,3700 oflhe Lahor Codc. for lhc pcrformncc of <br />lhc work lbr and policy numbc, uc: <br />Policy 4astvlT a )- ?-zt <br />-l <br />certify lhal in the pcrfbrronce of the work for which lhis pcrmit is issucd. I shall not cmploy any pcrson in any monmr <br />so as lo bccom suhjccl lo lhc wo*crs'compcnsalion lsws ofcalifornia, and agrcc tha( ifl should bccom suhjcct to lhe <br />wo*crs' comFEnsalion provisions of Scclion 3700 of lhc Lrtnr Codc. I shall. forthwith omply wilh thorc pmvisions.. <br />WARNING: Failurc to scurc workers'com;rnmtion covemge is unlawful. and shall subject an employer to ciminal Jrmlths and <br />civil fincs up to onc hundred lhousmd dolltrs (gloo.fi[). in sddition to thc cost of compcnsation. damges as providcd for the <br />fes. <br />I hcrcby afllrnl undcr pcnillly ofperjury that I nm liccnwd ofChuptcr 9 (commencing with Section 70U)) ofDivision 3 <br />of lhc Busincss and Prelcssions Code. md my liccnsc is in full forcc and clfccl. <br />Liccnsc Nilnrhcr:62736( <br />Conlractor:1 P-' P,.-,.,^.-^^ -*-T <br />CONSTRUCTION I FNDING ACENCY <br />I hcrchy alfirm undcr Jrnolty of pcrjury thal therc is a conslruclion lcnding l8cncy for thc Frfomnce of Ihc work for which lhir ffrmiI is <br />issucd (Sa. 1097, Civ. C.). <br />Lcndcr's Narnc: <br />Lendcr's Addrcss: <br />APPLICANl' DIICI ARA'I'I()N <br />I lrcrlby alllrm un(lcr pcntrlly ol'pcrjury orc of thc lblk)wing dcchrtt ionr: <br />I)ctrx)lition I'crillils-Arhcslos N({ilicntion Ftdcral Rcgulnli(ms ('l illc.10. l'nrlf)) <br />-Rcquirc(l <br />l.cltcr ol N(nilicalion <br />_l ccrlily lhal lhc fcdcrill rcSulalk)ns rcgarding rsttslos rcrilovalrrc [(il {pplicahlc k, this projcct. <br />4 ccnily thrt I hrrc rcad lhis applicalk)n aild stalc lhal lhc rtnrc iilli,rnEltrn i\ corcct. | ilgre to conrply *'ith all Ciry and County <br />ordinanccs and Statc l-a*'s rcllting to buildinS conslruction. nrkl hcrchy ruthorizc rcprcscntalivcs ofthis Cily and Couilty to cnlcr ulmn the <br />{bovc mnlioncd pmpcrly for <br />Appli(rnt 0r Agent <br />Pemritee trame (print)Otc Gn t-.O f <br />zg-20 <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 Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewer/Cap <br />Back Flow Device <br />Rouqh Plumbinq <br />Final Gas Test <br />Meter Release I <br />F!NAL 2 U/z,r'l ,M14n <br />Notes, Remarks, Etc. <br />S <br />"*$ ?-)0'26