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PLUMBING.INSPECTOR RECORD O a APPROVALS DATE ID/SIG COMMENTS OWNER BUTLDER DEI'ARATION I hqcby atfm unda panalty of pajury that I m ampt ftom thc CorlBcloB' Licre Lrw for thc hllowing ren (Sc.7031.5 Buins and Prcfeion Code): Any City or County which rcquic a pcmit to ontruct, alta, imprcvg damlish or rcpair uy structw, Fbr to its isBmcc, also rcquiB thc applicot for such pdnit to filc s signcd ststmat thd hc or slrc k licqNcd pumad to thc Fovisioru of thc Contractor's Licascd L:w (Chapta 9. Comocing with Sction ?000 of Division 3 of thc Bwins ud Prcf*ions Codc) or thst hc or she is cxmpt thsrtom ed thc bosis for thc allcgcd umptior. Any violation of Serion 7031.5 by 8ny applicut for I pcrrnit subjcts thc applicmt to a civil poalty of not morc thu fivc hundrcd dollm ($500). _1. I oms ofthc prcpary. or my cmployB with wag6 E thcir mlc compcrsaion, will do thc w* ed the stnrctE is not intandad or offcrcd for slc (S€.7(X4, BBins ud Profeiore Codc: Thc Contrsclor's Licre t w doe not 4ply to e om6 of thc prcpqty who hrilds or inpros ttEEtr fld who dc mh w* himsclf or hwlf or thrcugh his or ho om mploye, prcvidcd that such imprcmr rc rct irtodcd or olfqod for sh. lf, how, thc hrildirts or hprovsffin ie sld withia m )ry ofcorplctior! thc O!vr6 Buiklq wil haw thc hfda ofprovhg thd hc or strc dil rct tuiH or inprcw lhc propqty fu thc Frpo* of slc). -1. as owner of the propqly. am exclusively contracting with licensed contractors to construct the project (Sec. 7U4, Brsiness and Pnofission Code: The Contractor's Liccnse Law does not apply to an owner of property who builds or improves lhereon, and who contracts for such projects with a Contracto(s) licerscd pursuant to the Contractor's License l-aw). -l am exempt under Section-. B. & P.C. for this reason. I WORKERS' CONTPT',NSATION DECLARATION I hereby alTirm under pcnalty of pcrjury one of the follorving declarations: _l have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation. as providd for by Section 3700 of the I-abor Code. for the performance of the work for which the permit is issued. _l have and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for the performance of the work for which this permit is issued. My rvorkers' compersation insurance carrier and policy numhr are: _l certi& that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to bccome subjoct to the workers' compensalion laws of California. and agrec that if I should become subject to the workers' compcnsation provisions of Section 3700 of the labor Codc. I shall. forthwith comply with those provisions.. WARNING: Failure to secure workcrs' compdsation coverage is unlawful. and shall subject an €rnptoyer to criminal pcnalties and civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of comp€nsation, darnagcs as provided for the Section 3076 of the Labor Code, interest and attorncy's fe6. I hereby affrm under penalty .1 of the Business and Professions Code, and my license is in full force and effect. License Class: Liceosc Numbcr: W I hftby amm unds pcnalty of psjury thst thsc is a constructbn lcnding ag6cy for thc psfomucc of thc wrk for *tich this Fmil b issucd (56. 3097, Civ. C.). kndo's Nmc: I clttlcr's r\tlth t'ss. APPLICANT DECLARATION I hereby aflirm under penalty of perjury one of the following declarations: Demolition Permits-Asbcstos Notification Federal Regulations (Title 40. Part6) -Required Letter of Notilication -l cEtify thal the fedEal regulatioN regilding rbctos rmoval uc not applicable to lhis prcjcd. - I cgtiry thd t havc rad this application ed stalcthat the sbovc infomation is corcrt. I agrcto comply with all Cityand County ordinancG ild Statc lrws rclating to building comtruc-tion. md hcrcby authorize rcp.6cntaliv6 of this City ud Counlyto 6tq upoo lhc abovc motioncd prepcrty for impelbn purposa. Applicant or Agent Permitee nnnre flolo' UNDER GROUND Waste & Vent Water-Under floor Gas-Underfloor Building Sewer ArealStorm Drain I nterceptor/ CIa rifier TOP OUT Waste & Vent Water Piping Gas Pipinq 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 Sewer/Cap Back Flow Device Rough Plumbing Final Gas Test I Meter Release ^ I -,1 ^l_ t^)ra, F!NAL tqry/{/a(t0w1 wo0 Notes, Remarks, Etc.at Owner:_ Carrier:- Policv Number:l:rpit cs. Date:_Contractor: I