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PLUMBI NG.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DETTARATTON I hreby rffm undc paalty of pcrjury thd I m crmpt ftom thc CortracloF' Licw kw for thc following t@n (Sc.7031.5 Busincs and Profeion Code): Any City or Courty which rcquhc a pa'rnit to @NtrucL .ltq, improvq danolish or rcpair my struclurc, Fior to itr isumcc, dso rrquirs thc spplicst for such p6mit to filc s signcd starmt that hc or shc is licoscd plmet to thc Fovisiom of thc Contrsctor's Licoscd trw (Chaptq 9. Commcncing with Sction 7000 of Division 3 of rhc Buine ud Prcfcsions Codc) or that hc or shc b cxcmpt thgrftom md thc bosis for thc allcgcd crmption. Any violation of Scrion 7031.5 by 8ny spplicst for 8 pcmit subjcts thc spplicant to a civil pmlty of not morc thm fivc hundrcd dollm ($500). -1. as owner of the property, or my employees with wages as their sole compensation. will do thc work and the sructtne b not intendod or offered for sale (Sec.7044, Business and hofessions Code: The Contraclor's Licaue l-aw does not apply to an owner of the propcrty who builds or improve thmn, and who does such wort himself or herself or through his or her own employees. provided that such improvanents are not intendod or offercd for sale. If, howet/er. the building or improvement is sold within one ).car of complaion. the Ourner Builder will have the hrden of proving tha he or she did not build or improve the propcrty for the purpose of sale). #1, and as owner of the property. am exclusively contracting with licensed contractors to construct the p,roject (Sec. 7044, Business Pnofessbn Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon. who contracts for such projects with a Contracto(s) licarsed pursuant to the Contractor's License Law). _l am Drte: under e. a /c. for this reason.ill-?.5 ()rr'ner:X @ of the following defiarations:I hereby alTirm under penalty of perjury one -l have and will maintain a Certificate of Conscnt to Self-lnsure for work€rs' compquation. as provided for by Section 3700 of the I-abor Code, for the performance of the work for which the pennit is issued. _l have and will maintain workcrs' compensation insurance, as required by Section 3700 of the l-abor Code, for the performance of the work for which this pernrit is issued My workers' compensdion insurance carrier and policy number are: Policy b certitythat in the performance of the work for which this permir is issued. I shall not employ any person in any manner $ rs to become subject to the workers'compersalion laws of California and agree that if t should become subject to the workers' compensation provisions of Sertion 3700 of the l,abor Code. I shall. forthwith comply with thosc provisions..I WARNING: Failure to secure workers' compensation is unlawful. and shall subject an onployer to criminal pcnalties and civil l'ines up lo one hundred thousand dollars ($100.000).addition to the cost of compcnsation, damages as provided for the Section 3076 Code. interest and attorncy's fecs. ?b>z ) I hereby affrrm under penalty of perjury that I am licensod provision of Chapter 9 (commencing with Scrtion 7000) of Division 3 of thc Business and Professions Code. and my license is in full force and effect. License Class: License Number: W I h@by affm undd pcnalty of pajury rhst lh@ is I @nsirucrion lading ryocy for thc pcfommcc of thc rcrk 6r which this psmit is Civ. C.). Lendcr's Address: APPLICANT DECLARATION I hdry aflinn under penalty of perjury one of the following declarations: Demolition Perrnits-Asbestos Notification Federal Regulations (Title 40. Part6) _Recluired lrtter of Notification _l ccrti& that the lederal regulations regarding asbcstos removal are not applicable to this project. the above information is conect. I agra to comply with all City and County and hcreby authorize represefltatives of this City and County to enter upon the Applicant or Agent l'ermilee nBme to building *,", t/fz.{fzozn UNDER GROUND Waste & Vent Water-Under floor Gas-Underfloor Building Sewer Area/Storm Drain I nterceptor/ Cla rifier TOP OUT Waste & Vent Water Piping Gas Piping Roof Drain Tub/Shower Test Rouqh 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 Sewer/Cap Back FIow Device Rough Plumbing Final Gas Test Meter Release t-) F!NAL V-\L\"Aco *.J [.)()' Notes, Remarks, Etc. Carrier: l:rpircs. Dnle:Clontractor: