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PLUM BING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUII,DT]R DEI,CARATION <br />I hcrchy allirnr undcr pcnahy of pcrjury that I anr cxcmpl liom thc Conlrlck)n' Licctrsc hw ftrr thc lbllowirUl rcason (Scc.7l)-11.5 <br />Businc\s ond Prolcrsion C(xlc): Any City or C(runty which rcquircs a Jrcrnrit to conslrucl. {llcr. imp()vc. dcnblish or rcpilir any <br />slruclurc, prior k) ils issu{ncc. also rcquircs lhc applic{nl lbr s[ch Errit to lilc il signcd slalcrrcnl lhnl hc or shc is liccnscd pursuant <br />k) lhc provisions of thc C-'otrtrnctor's l-iccnscd law (Chnftcr 9. Conrnencirg *ith Scctbn 7(xx) of Division J of lhc Bushrcss and <br />l'mlcssi(rnsCodclorthathcorshciscxcmpllhcrcfromrndthch0sislbrthcillhgcdcxcmption. AnyviolalionofSslionT03l.5hyilny <br />npplic{nl lbr a pcrtrrit suhjsls lhc applicant to il civil pcnally of [ol morc lhan livc hundrcd dollus ($501)). <br />I <br />-{1. n* .wncr of th. prelf,ny. or my cmployccs s'ith wngcs as lhcir slc comFnsali(nr. willdo lhc sork oxl lhc stMturc is not <br />hrlcnclcd or offcrql lbr slc (Se.7044. Busircss ilnd Protcssions (-rxlc: 'l hc Conlractor's l.iccnsc l.ilw docs nol apnly k) nn owlcr of <br />thcpn)Fny whohuildsorimprovcslhcNn.afilsho(l(rssuchqorkhirnsclforhcrsclforthroughhisorhcrosncnnloyccs. <br />Irroridcdrhalsuch imprc\'ctrEnls&mliilcdcdorolltrqlforsh. ll.ho$crer.thchuiklingorimprorcrrcnlissklwithinorc)riu <br />ofconrplcliol lhc Owncr Buildcr will hrvc thc hurlcn ofproving that hc or shc dirl not buikl or iilprovc thc pRrff,yly for lhc purynsof <br />ule). <br />-fl. as owncr ofthc pK)JEny. dm cxclusivcly cotrlracti[E wilh Ii(ctr$d conlrilctors lo ((,nstrud tlf, fojccl (SN. ?(X.1. Busincss <br />ad Ptrrlijssk[ Codc: Thc (-'ont]aclor's l,iccnsc Lrw docs nol apply kr u owncr ofpro|crty who huilds or inrprovcs lhcrcon. <br />^T,who conlracls for such projecls wilh a Contractor(s) licenscd pursuant to the Contraclor's Liccnse Law). <br />ulr(lcr B. & P.C. f<rr this reuson. <br />( )n ner:{*u4 NaUYEU <br />I hcrcby affirnr under Fnalty of perjury onc of thc <br />IVORKT'RS' C( INT PENSATION <br />DECLARATION <br />lirlkrwirrg dccllral ions: <br />l-atxrr Cl<xlc. for thc pcrfrlrrturncc of thc work lor which thc pcrnrit is issuctl. <br />#havc and will nrairrlain workcrs'.i7fi) of thc Luhor Code. for lhe pcrfonnarrcc of <br />work ftrr which this pcnnit is issucd.and policy number arc: <br />1 l*rlzt <br />that in thc pcrformancc of thc work lirr which this permit is issued. I shall not <br />[ -l , <br />crnpkry irny pcrs()ll in any rnanncr <br />shoukl hccortrc suhjcct to thcso as to bcconrc sub.[.ct to thc workcrs' compcnsation laws of California. ancl agrce that if I <br />u'orkc'rs' comJrcnsation pnrvisions of Scction -17(X) of thc Lrtnr Culc. I shall. lirrthu'ith conrply with tho*- provisions.. <br />WARNIN(i: Failurc to sccurc workcrs' c<llnpcrrsation c()\'crrgc is unlawlul. arrd shall subjecl an crnploycr lo crintinal Jrcnaltics and <br />civil tincs up to onc huntlrcd lhousantl dollars (SlU).(XX)). in adrlition lo lhc cost o[ conrJrcnsalion. danurgcs as provided for the <br />.Scction .1076 lltc Code. intercst and altorlrcy's lccs. <br />l)ale:Appllcant:_-+1o* Ua-ttVtnJ <br />LICF'NSED CONTRACTOR <br />DECLAITATION <br />I am licensed under povlsion of Chapter 9 (comnrcrrcing with Section 7m0) of Division 3 <br />t my liccnse is in full force and effect. <br />I hcrcby at[irrn under pcnalty of pcrjury that <br />of thc Busincss and Pmfessions Codc. and <br />I.icensc Nunrbcr:4eL1 g <br />b conrracro,, +1o* <br />^IkttveNW <br />I hercby 8fftrm undcr Fmlty of perjury that tlw is a construction bndirg sgercy for the Jrc fomrce of thc wtrk for which this lmit i3 <br />issucd (SN. 3(B7, Civ. C.). <br />knder's Name: <br />lrndcr's Addrcss: <br />APILIgANLDECI.AEAIION <br />I hcrcby atrmundcr Fnally of pcrjury orc of thc following dccltrations: <br />Demlilion Permitr-Asbcslos Notification Fcdcrsl Regulalions (Titlc 40. Pan6) <br />R@uircd [atrc] of NolifErlk n <br />\ <br />-Vccrtify thal lhc fcdcrsl Egulations rcgarding ssbcstos rcru)vllorc mt opplicablc to this pmjst. <br />y I ccnity that I havc rcad lhir applicrtion dd stste that Ihc rtnrc infomtion is coret. I agre to omply uith all City ud Counly <br />ordinanes and Statc l:ws rclating to building conslruction. afll hcrcby ruthorirc reprcsnlatives ofthis City and Counly lo cnler ufnn lhe <br />atxlvc mentioned property for inspection purynses. <br />Appliurnl or i\genl <br />Itrrlrtitee nlnltr <br />UNDER GROUND -4. <br />Waste & Vent Th *\YU <br />Water-Under floor I ( <br />Gas-Underf loor <br />Buildinq Sewer <br />ArealStorm Drain <br />I nterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test 0 1)b(.ft Y 7 <br />Rough Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />Main Drain/Pool Pipins <br />Fill Line/Back Flow <br />Poo! Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary SewerlCao <br />Back Flow Device <br />Rouqh Plumbinq <br />Final Gas Test <br />Meter Release tl J )/, <br />FINAL L t0 L0 >fl-wt <br />lrNotes, Remarks, Etc. <br />(