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PLUMBING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS <br />UNDER GROUND <br />Waste & Vent <br />Water-Underfloor <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 />Ptrap/Drain Line <br />Main Drain/Pool Piping <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Misc <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 />(I It -2-FINAL 5 Itn "l O DW)) a:7r6 / <br />Notes, Remarks, Etc.ut,- t <br />Orrncr-Euildcr Dccluation <br />I hgcby aflim unda pcmlty of pcrjury thst I am .xcmil form the Contrsctors' Liccn* kw for tlrc following r@tr (sE 7031.5lEin6s <br />ud Prcf6sioo Codc): Any City or County which rcquiru r pcmh lo o6tBcl. ahfi. improvc. dmolish or rcpah ey structua. dh.' to fu <br />issuncc, rlso rcquirc thc spplicsot for such pcmh to filc a rigncd 3tEtmcot thrt hc or shc b liccEd puBusd to thc prcvisior o-rthc <br />Conmcmr's Lienscd Law (Chaptc 9, Commcrcing with S61ion 70OO of Division I of thc BBin63 rnd ProfB3ioB Co&) or thst hc or <br />shc is cxempt thqctom and thc bssi! for thc rllcgcd cxcmption .Any viohtiotr ofscction 703 1.5 by uy rpplicmt for s pcmh lubjccts thc <br />applimt to r civil pcmhy of rct morc the five hudrcd dollm ($500). <br />_1. 6 owncr of thc prcpqny, or my employcd with wagcs I thcir solc coap€ffation, will do thc work ud thc atructuc is not intrndcd <br />or off€red fo, slc ( 56.7044, Bwin6s snd ProfBsionr Codc: Thc Contractor's Liccroc Law doa not apply to 8n owrcr ofth! prcps'ty <br />who buil& or improvB thcrco, md who doe such work hiruclf or hGlf or through hb or h6 owtr cmploycB, providcd thlt such <br />imprcvmcnts uc not intcndcd or otfacd for slc. lf, howcvq. thc building or improvmmt is sold wilhin onc y6 of complction. thc <br />Owu-Buildq *ill havc thc budcn of proviDg thlt hc or shc rct build or improvc for th€ purposc of elc). <br />_1. a o*nq of thc prcpclty. m crcluivcly contnctitrg wilh liccNcd contnctoG to @Ntruct thc Fojet ( Str. 7044. Buio6i md <br />Pofsion Codc: The Contrrdor'i Lienrc bw doa mt apply lo rn omq of propcny who builds or improve thcron , and who <br />contracs for ruch proj6B with I Contndor(r) lic@scd pursunt to th. Contrador's Liccn* [rw.). <br />I m cxcmpt under Scction & P.C. for this roon. <br />Date:Owno: <br />WORKERS COMPENSATION DECLARATION <br />I hscby sflim und6 pcmlty of pojury on€ of thc following delsratioN: <br />_l hsvc and will maintain a Ccnificatc of Coscnl to Sclf-lnsure for workers' com;rcmtion, as provided for by Setion 37OO of the <br />[:bor Codc. for thc pcrfomncc of thc work for which thc pmit is issucd. <br />_l have and will maintsin wortcrs' ompemtion insurance. r required by Section 1700 of the Lrbor Code, for the perforroncc of thc <br />work for which this permit is issued. My workers' compenution insurancc caric ad policy numbcr arc: <br />Cuicr: <br />Policy Numbcr: <br />(This setion necd not bc complctcd ifthc pcmit is for Chc hundrcd dollaB {$1001 or lcss) <br />_l ccfliry thst <br />beame subjet r <br />is i$ucd. I shsll not cmploy any pcron in any manncr so s to <br />to thc worken' ompen*tion hws agre that if I should subjat to the workers' <br />compcosation provisiom ofS6tion 3700 ofthc hbor I shall. <br />WARNING: Failure to secure workcrs' compensation covcragc is unlawful, and shall subjcct m to qiminal pcnaltics and civil <br />fines up to one hundred thousand dolla6 ($100,000),in addilion lo lhc cost ofcotnpensation. darnflges as providcd tor thc Seclion 1076 of <br />the Labor Code, interest and attorney s fees <br />LICENSED CONTRACTORS DECLARATION <br />I hocby.ffm undq pcultyof pcrjury thal I m licoscd uods prcvision of Chaptr 9 (@mcncing wirh Sectiotr 7000) of Divbion 3 of <br />thc BBim lod Prcfosioro Codc, md my liccc is in fuU forcc md cff(t. <br />in lhc pcifomncc of thc work for which this pmh <br />ofCalifornir, rnd <br />I rce'nsc'( hss <br />Date: <br />CONS TRI'C'IION LENDING AGENCY <br />I hereby aflirm under pcnally ofperjury that there is a conslruction lcnding agcncy for thc pcrfonnance ofthe rvork for which this perDit is <br />issued (Scc. 1097. Cir. C.). <br />Lender's Namc: <br />APPLICANT'S DECLARATION <br />Dcmlition Pmib-Asbcstos Notificstion Fcd68l Rcgulations (Titlc 40, Prn 6) <br />_ Rcqutcd t ttqofNotificrtion <br />_l ccfliry thst thc fcdral rcSulatioro rcguding sbBtos rcmoval ec not applicsblc lo this prcjst. <br />_ I ccrtiry that I havc rcad this application and statc that thc above infomation is corcct. I agrcc to comply with all City and County <br />ordimncG and Ststc lrws rclating to and rcpr6cntEtivcs ofthis City Etrd County to cntcr upotr thc <br />Pmittc tmc (print): <br />Fxnir.c. <br />lrnds's Addr8r