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PLUM BING.INSPECTOR RECORD <br />APPROVALS DATE !D/SIG.COMMENTS 0WNER BUILI'I:R DEI,CARATI0N <br />I hcrchy allirm undcr pcnnlty of perjury that I {N cxcnrpt fmm thc Crnilrilck)rs' I.iccnrc hw for thc followirrg rca$n (SccJ0-11.5 <br />Busincss lnd Profcssion Ctxlc): Any City or Counly shich rcquircs a lf,rllit k) construcl, ahcr. improvc. dcnmlish or rcpair ony <br />slructurc, prior to ils issuutrcc. {lso rcquires thc 0pplic0nl for such Frmil k) lilc n sigrcd slalcnEnl lhat hc or shc is liccnsd pursuanl <br />lo lhc provisions of lhc Conlrdchr's l,iccnsd ljw (Chilptcr 9. Commcncilg s'ilh Scclion 70(X) of Division J of Ihc Busincss aul <br />PRrfcssionsCode)orlhrthcorshciscxcmpllhcrcfromnndthcbasisforlhcilllcgcdcxcmption. AnyvkrknionofSationTO.ll.5byany <br />applic{nl i)r a Jf,rlrit suhjccls thc applicant lo a civil pcnrlly ol nol rmrc than fivc hundrcd dollffs (!is(D).,/lI-1. as owncr of lln' floJrc]ty. or my cmployccs with wngcs as thcir $lc coorlEnsali(nr. will do thc work dnd thc slructm is not <br />iucndcd orollcrctllirrslc(S('.TO44.BusimssandPrclbssionsCodc:'lhcCoflrilclor'sLhcnscl,uwdocsnolapplyloanowncrof <br />lhcpmFny whohuildsorirymrrrsthcmn.Mlwlmd(Essuchrrrrlhirnstlforhcrsclforthnrughhisorhqowncnrployccs. <br />providcd lhat such imp(llctrrnls arc nol incnrlctl or ollcrttl for slc. Il. hoc'clrr. thc buiHing or iilpro\cnrcill is $H wilhin oilc }{tr <br />ofcofiplclknr. Ihc Owncr l]uildcr will lHvc llE hurdcn ofproving thill lE or shc (lid not build or hrpn)vc thc pft,Frcdy li,r thc purF)s of <br />*rlc). <br />_1. ns owncr of lhc propcny. am cxclusivcly conlracling wilh liccnscd coilruclors k) construcl llrc prejccl (Scc. 7(N4. Busincss <br />anl Ptrrfcssiu Cirdc: 'l'hc Cbnlraclor's l-iccnsc L{w docs trol apply lo an owocr ofpropcrty who builds or improlcs lhcrcon. <br />and who conlRclslbrsuchprojccts$'ilhaLbnlmcto(s)liccnscdpursuanttrthcCoilraclor'sLiccnshw). <br />-l <br />an cxcnrpt undcr SBlion-. B. & P.C. for lhis rcrson. <br />Oc,Waoarc, 1 20 -LO Owner:- <br />I hcreby affirm undcr Fnelty of perjury one of thc folkrwing dcclarations: <br />-l <br />havc und will maintain a Ccrtificatc of Conscnt to Sclf-lnsurc for workcrs' comgrensalion. Bs providcd for by Scction 37U) of thc <br />Labor Codc. for thc Jrcrfornrance of thc work for which thc pcrmit is issued. <br />_l havcandwill maintainworkers'corngrcnsalioninsurancc.as requiredbySection.lT0Oofthc[:borCode.forlheperformunceof <br />thc work for which this prmit is issucd. My workcrs' conrJrensation insurance carricr and grclicy numbcr are: <br />Carrier: <br />Policv Number: ' Exoircs: <br />-l <br />certify that in thc pcrformancc of lhc work for which this Jrcrrnit is issued. I shall not employany person in any manrrcr <br />so as lo bccomc subjcct to lhe workers' compcnsnlion laws of California. and agrcc lhat if I should bcconrc suhjcct to the <br />workers' compcnsation provisions of Scction 37fi) of thc l-.atnr Codc. I shall. forthwith comply with those provisions.. <br />WARNING: Failurc lo securc workcrs'compcnsation covcragc is unlawful. and shall subjcct an employcr to criminal gnnaltics and <br />civil lincs up to onc hundred thousand dollars ($100.fiX). in addition t<l thc cosl of compcnsation. damagcs as providcd for thc <br />t and attorney's fccs <br />o*", 1-2o 20 Appucanr: € td-a 0clu"a <br />LICENSED CON'TR/T C'TOR <br />DECLARATION <br />I hcreby atllrrn undcr pcnulty of pcrjury that I arn liccnsctl undcr provision of Chaptcr 9 (commcncing with .Scction 7firu) of Division .l <br />of thc Busincss and Professions Codc. and nry liccnse is in t'ull frrrcc and ctlt'ct. <br />License Class: License Numbcr: <br />Date: Conlractor:_ <br />W <br />I hcrcby lmrm undcr ]Enalty of pcrjury lhat thsc is a snstruction lcnding ogcncy for thc pcrformarcc of thc work for which this lrcmit is <br />issucd (Ss. 3097. Civ. C.). <br />lander's N{mc: <br />Lcndcr's Addrcss: <br />APPI ICANT DT'CLARATION <br />I Myatrirmunder pcnalty of perjury one of the following declarations: <br />Dcmolition Permits-Asbestos Notification Federal Regulations (Title 40. Parl6) <br />-Required <br />Letter of Notifrcation <br />-l <br />ccnify th0t thc fcdcral rcgulations rcgarding asbcslos rcmovalarc not applicablc kr this prejsl. <br />-l <br />ccrtity lh{l I havc read lhis applicaliur and slatc lhal lhc atxrrc infrrrmtkrn is corNl. I a8re k) comply wilh all City and Counly <br />ordinanccs lnd Slalc liws rclilting to building constructkln. {nd hcrchy aulhorirc reprcsentuivcs ofthis Cily and Counly to entcr upon lhc <br />atxrvc mcntioned propcrly for <br />Applicant or Agenl <br />Pernritee nnme <br />7--o*", 1'20'70 - <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf loor <br />Buildinq Sewer <br />ArealStorm Drain <br />I nterceptor/ CIarif ier <br />TOP OUT ,,1 <br />Waste & Vent 0 7 <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 FIow <br />Pool Heaterlcas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary SewerlCap <br />Back Flow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release (^l a. <br />F!NAL \1/!1fl41 t1 WT <br />INotes, Remarks, Etc.ll <br />lDrrrg