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PLUMBING.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARATION I hmby affrm undo poalty of pcrjury that I m cxmpt fiDm thc Crtrt rctoE' Licffi ls for the following rcmn (Sc.7031.5 Buincs and Profeion Codc): Any Cily or County which rcquirB a pqmit to snstruct, altc, imprcvc, danolish or rcpair my strucluc Fior to its issumcc, also rcquiB rhc applicilt for such pcrmit to filc a signcd stamt thd hc or shc b licascd Fmatt to thc provisioB of thc Contmtor's Licmscd Law (Chapt6 9, Comacing with Sction 7000 of Divicion 3 of thc Buiffi md PrcfcsioB Codc) or that hc fi shc is qmpt thqcfrom ud thc bosb for thc 8llc8cd smprion. Any viol*ion of Sctior 7031.5 by oy applicant for a pcrmit subjat! thc applicmt to I civil pcnalty ofnol morc tho fivc hundrcd dollm (3500). -1. 8s owner of the property, or my employecs with wages as their sole comporsation, will do thc wo* and the sffincture is not intendod or offered for sale (Sec.7O44, Business and hofcssions Code: The Contraclor's License law does not apply to an owner of the propcrty who builds or inrprov€s thcron, and who docs such wort himsclf or herself or through his or her own employec, provided that such improvorrcnts are not intended or offered for sale. If. however. the building or imp,rovement is sold within onc )ea of complaiorL the Orvner Builder will have the hrden of proving tha he or she did not build or improve the propcrty for the prposc of sale). _1, as owner of the property. am exclusively contracting with licensed contractors to consruct the project (Sec. 7044. Business and Proftssion Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. and who contracts for such projecrs with a Contractor(s) licensal pursuant to the Contractor's License Law). -IamexemptunderSection-.B.&P.C.forthisreason.l):rte WORKER,S' COMPENSATION DECLAR/ITION I hereby affirm under penalty of pojury one of the following declarations: _l have and will maintain a Ce.rtilicate of Consent to Self-lnsure for workers' compensation, as provided for by Section 3700 of the Labor Code. for the performance of the work for which the permit is issued. _l have and rvill maintain workers' compcnsation insurance. as required by Section -3700 of the l-abor Code. for the performance of the work for which this pcrmit is issued. My workers' compcnsation insurancc carrier and policy number are: t-(/(..- t ()-52/r-tf -trLlPolicy _t certi& that in the pcrformance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers' compensation laws of California" and agree thal if I should become subject to the workers' compensation provisions of Section 3700 of the l",abor Codc, I shall. forthwilh comply rvith those provisions.. WARNING: Failure to secure workers'cornpensation coverage is unlawful. and shall subject an anployer to oiminal penalties and civil fines up to one hundrcd thousand dollars ($100.000). in addition to the cost of compensation, damages as providq,l for the Section 3076 of the labor Code. interest and attorncy's fees. ll-r -Lc Lc Cln, I hereby affrrm under penalty of pcrjury that I am licenscd under pnovision 9 (commorcing with Section 7000) of Division 3 of thc Business and Professions Code. and my license is in full force and effect. Licensectrrr' ' CIL LicenseNumber:) trruloLl W I hcrc:by affm udr pqnlty of pajury thd th@ fu s onsruction lodiry ag@y for thc pcfomcc of thc md. frr whkh thb pqmit b iscd(Se. 3097. Civ. C.). I cltrler's )(irttte : Lcnder's Ad&ess: APPLICANT DECLARATION I hcreby aflirnr under penalty of perjury one of the following declarations: Demolition Permits-Asbcstos Notification Federal Regulations (Title 40. Part6) -Required Letter of Notification -l cstiry thd thc ftdcral rcgulatioro rcgrrding rbatos mval re not qplicrblc to thb polrl. / t -riry ,a, , ,ruc rqd thb applicetion dd statc thd tlE .borc inforEdion b @rcl. I agc lo omply with all City md Couty oditlffic and Stac [:w abing to building orutru.rion ed h6cty authoriu rcprBmtativB of this City ed Couty to 6tq upotr thc above mcntioned propcrty for Applicnnt or Agent Permitee nnme <-C-rt-2 t-lL-Lol-c UNDER GROUND Waste & Vent Water-Under floor Gas-Underfloor Building Sewer ArealStorm Drain I nterceptor/ Cla 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 Piping Fill Line/Back FIow Pool Heater/Gas Line Miscellaneous Gas Service Water Service Lawn Sprinkler Sanitary SewerlCao Back Flow Device Roush Plumbins Fina! Gas Test Meter Release I ir .J FINAL le.t+lu NILW 6IY Notes, Remarks, Etc.t b ,",u, P I L-)-)ou? conrrecto*X Pt,y^tr,^., /L'lcl'rt./-