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PLUM B!NG.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER DUILDER DELCARATION I hmby affm unda pcnalty of pct'ury thrt I m cxcmpt from thc ContracloB' Licre tiw for thc following l@n (Sc.7031.5 Buincs ud Profsion Codc): Any City or Cowty which rcquira a pomit to @nstruct, altq. improvc danolish or rcpoir my 3tructurc. Fbr to its isumcc. also rcquire thc eplicmt for such pcnnit to filc I signcd stdqmt thal hc or shc b licq&d plmut to thc provisiom of thc Contrctor's Liccnscd lzw (Chaptq 9. Commmcing with Setion 7000 of Division 3 of thc Buhs ud Prcfsions Co&) or that hc or shc is smpt thactom ed thc bssis for thc sllcgcd qmprion. Any violation of S€rioo 7031.5 by ey spplicutforapcmitsubjetsthc applicuttoacivilpcn8ltyofmtmorcthafivchundrcddollm($500). -1. as owner ofthe property. or my cmployees with wages as lhcir sole compensation. intendod or offered for sale (Sec.7O44. Business and Professions Code: The Contractor's Liccnse Law does not apply to an owner of the property who builds or improves thcron. and who does such work himself or hcrself or through his or hcr own employees. provided that such improvonents are not intcnded orofferod for sale. lf. howcver. the building or improvement is sold within one year of complaiorL the Ourner Buildcr will have the hrden of proving that he or shc did not build or improve the propoty for the purpose of sale). -1. as owner of the prop€rty. am exclusively contracting with licensed contractors to construct the project (Sec. 7044. Brsiness and Pnofession Code: The Contractor's License Law does not apply to an owner of propcrty who builds or improves thereon. and who contracts for such projects with a Contracto(s) licenscd pursuant to the Contractor's Licensc taw). _l am exempt under Section-. B. & P.C. for this reason. I ):tlt' ( )tr rtcr' WORKERS' COMPENSATTON DECTI\RATION I hereby affrrm und€r penalty of perjury one of the following declarations: -l have and will maintain a Certificate of Conscnt to Self-lnsure for workers' compensation. asl pnovided for by Section 3700 of the Labor Code, for the pcrformance of the work for which the pcrnrit is issued. -l have and will maintain workcrs' compensation insurance, as required by Scction 3700 of the labor Code, for the pcrformance of the work for which this pcnnit is issuod My workcrs' compensation iruurance carrier and policy number are: Policy N"^b*, -/ q2-(9b\t> Expires:tZ-Z)-Zc _-l certi& that in the performance of the work for which this permit is issued, I shall not anploy any person in any manner so ,rs to become subject to the workers'compensation laws of California. and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall. forthwilh comply wilh those provisions.. WARNING: Failure to s€rcure rvorkers'is unlawful. and shall subject an onployer to criminal groraltics and civil l-rnes up to one hundred thousand ($addition to cos of compensation, damages as Eicvided for the Section 3076 of the tabor Code. interest and attorney's o -\5- I hereby affirm under penalty of perjury that I am licensed 9 (commencing with Section 7000) of Division 3 of the Business and Profcssions Code. and my licensc is in full force and effect, Numbcr:5>abl - W I hatby affmudr pqultyof pcjurythd thft b a onnrudbn lcoding agmy for thc pqforrltmc ofthc rcrt 6r whichthis psmit b issuod (Sc. 3097, Civ. C.). lrnder's Namc: I-ender's Ad&ess: APPLICANT DECLARATION I hereby affinn under penalty of pcrjury one of the follorving declarations: Demolition Pennits-Asbestos NotiFrcation Federal Regulations ('l'itle 40. Pan6) -Reauired Lctter of Notification -l certi$ that the federal regulations regarding asbestos removal are not applicable to this project. _l certi& that I have read this application and state that ordinances and State Laws relating to above mentioned property for Applicant or Agent Permitee neme orr", lo-6'u UNDER GROUND Waste & Vent # Water-Under floor Gas-Underfloor Building Sewer Area/Storm Drain I nterceptor/ Clarifier TOP OUT Waste & Vent'f Water Piping Gas Pipins Roof Drain Tub/Shower Test Rouqh Water Heater POOL/SPA P-trap/Drain Line Main Drain/Pool Pipinq Fill Line/Back FIow Pool Heater/Gas Line Miscellaneous Gas Service Water Service Lawn Sprinkler Sanitary SewerlCao Back Flow Device Rough Plumbins Final Gas Test / Meter Release tl I AI /d/ FINAL u//6/4t lffrltfr I6/6tJ Notps, Remarks, Etc.t\ I / [4fYri li t0' W *) r 'Mi$,t,'t v1,) vyil Ws6 1 U' \ ^- {r