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PLUM BING.I NSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUTLDER DEI,CARATION t hmby allim unda poalty of pcrjury thar I m crcmpt ftom thc Contrelon' Licrue taw hr thc followiig @n (Se.7031.5 Buines ard Prcfcion Codc): Any City or Couty which rcquiB a pdtrit to construct. alta. improvq damlish or rfrir my structurc Fbr to its isumcc. also rcquira thc ryplicut for such pcrmit to filc a signcd $dmmt thd hc or shc b liccnscd pwant to thc prcvisiom of thc Cotrtractor'! Liccoscd Lrw (Chapt6 9. Commming with Sction 7000 of Divisioo 3 of thc Buine md Prcfsioro Codc) or that hc or shc is cxmpt threfrom ud thc basi! for thc allc8cd qdn6ion. Any violarion of Setioo 703 I .5 by oy appliciltforap6mitsuhietsthc spplimttoicivilp6ahyofmtmorcthofivehun&cddollm(1500). _1, as owner of the property. or my employee with wages as their sole compensation. will do the work and th€ structune b not intcnded or offered for sale (Sec.7044. Business and Professions Code: Thc Contractor's License law docs not apply to an owner of the propcrty who builds or improvcs thenon and who does such wort himself or hersclf or through his or her own employce. provided that such impnovenrents are not intended or offcrcd for sale. I(, howevcr. the building or improvernent is sold within one ],Ear of complaior\ the Ourner Builder will have the burden of proving thd he or shc did not hrild or improve the propoty for the purposcof sale). _1. as owner ofthe propefly, am exclusively contracting with licerued contractors to construct the project (Sec. 7044, Business and hofilssion Code: The Contractor's License Law docs not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a Contractor(s) licenscd pursuant to the Contractor's License Law). -l am exempt under B. & P.C. for this reason. WORKER,S' COM PENSATION DECLARATION I hereby alTirm under penalty of pcrjury one of the following detlarations: _l have and will rnaintain a Certificate of Consent to Self-lnsure for workers' compcnsation. as provided for by Section 3700 of the tahr Code. for the performance of the work for which the permit is issued./y[ havc and rvill maintain workers' compensation insurancc. as rcquired by Section 3700 of the l-abor Code. for the po'formance of thc work for rvhich this permit is issued. My u'orkcrs' compensation insurance carrier and policy number are: Go r.o of{L\r"nqt Policy lil, /no',o t I -l certi$, that in the performance of the work for which this permit is issued. I shall not €mploy any person in any manncr so as to bccome subject to the workers'compcnsation laws of California. and agree that if I should become subject to the workers' comp€xsation provisions of Section 3700 of the Labor Code. I shall, forthwith comply with thosc provisions.., WARNING: Failure to secure workers'compensation coverage is unlawful.shall subject an employer to criminal penalties and compensation, darnages as providcd for thecivil fines up to one hundred thousand dollan ($100.000). in to of attorney's fees./ DECI"AITATION I hoeby affrm under penalty of perjury that I am licensed under pnovision of Chapto 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my liccnse is in full forcc and efhct. License Number:Qnzqg fu-+ t^,nbt l+a{At/ W I hcby alfm uda pqr.lty of psjurythd thft ie 8 sndrucriotr koding 0gmy for thc pqfotmc ofthc rcrt for wtich this pgmi b isucd (Sc. 3097. Civ. C.). I crrtlcr 's Nluttc. Lcnder's Address: APPLICANT DECLARATTON I hrcbyaffirm under penalty of perjury one of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations (Titlc 40, Part6) -Rcquired Letter of Notification _l certi& that the federal regulations regarding asbestos removalare not applicable to this project. _l certiS that I have read this application and state that the above information is correcl. I agree to comply with all City and County ordinances and State laws relating to building hcreby authorize representatives of this City and County to enter upon the above mentioned propcrty for inspcction Applicnnt or Agent Permitee name (print): ,,," ulrr,l ,t6"o UNDER GROUND Waste & Vent Water-Under floor Gas-Underfloor Building Sewer ArealStorm Drain I nterceptor/ CIa rifier TOP OUT Waste & Vent Water Pipinq Gas Pipins Roof Drain Tub/Shower Test Rough Water Heater POOL/SPA P-trap/Drain Line Main Drain/Pool Pipinq Fill Line/Back Flow Pool Heater/Gas Line Miscellaneous Gas Service Water Service Lawn Sprinkler Sanitary SewerlCao Back Flow Device Roush Plumbins Final Gas Test Meter Release ll FINAL l'u\llt Notes, Remarks, Etc. Contractor: