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PLUM BI NG.I NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUILI'ER DEI.CARATION <br />t hqcby alfm un&r pqulty of pcrjury thd I m qmpt frcm thc Cootrrclots' LiccE L:w for thc followitrg rcn (Se.7031.5 <br />Buinas ad Profcaion Codc): Any City or County whkh rcquiB a pqmit to orutrud, 8ltq. impro'rc damtish or rcpair uy <br />structuc. prior to its isumc. also rcquis thc applicet for such pcmit to filc a signcd stalmmt that hc or dr b licord pmant <br />to thc provbioG of 0E Contr8cltr's Licascd Lrw (Chapts 9. Comcrcing with Sction 7000 of Divigion 3 of thc BsiB md <br />Prcferiom C.odc) or thst hc n shc is cxmd thfrftom md thc tssis 6r thc allcgcd aoption. Any violation of Sclbtr 7031.5 by ily <br />applicantforapemhsubjetsthc applimttoscivilpcmltyofnotmrcthehvchuo&cddollm($500). <br />_I. s ow6 of thc !tropaty. or my mplo)6 with wag6 I thck $lc ompatsdion, will do thc rc* ard thc srudE is mt <br />intardcd or offcrcd for slc (Sc.7044. Buine md Profeioro Codc: Thc Coilnc{or's Licffi lrw do6 nol rpply lo e oMq of <br />thc Fopqry who huiHs or hpro6 thcut [d who d6 Mh rcd( hirclf or hmlf or thrcugh his or hq om mployce, <br />prcvidcd that such impourmts m mt intadod or oftrod 6r sb. If, trcM. thc hilding or imprcwmau is sH within onc )q <br />of onplaion thc Owm Buiklc will harc thc hrdsr of proving thd hc or shc dil mt build or imprcrc thc tropcry for 0E Frp6c of <br />sh). <br />-1. <br />I owG of thc Eopqty, m qclusivcly sntre{ing with licaucd ontractoB to onsruct tlE projEl (Se. 7044, Bwins <br />and Eoftslm Co&: ThG Cootrutor's LiccM liw doB not 8pply to u owtr6 of propqly who builds or improvG th6@tr <br />and who orllnc{s for such projcls with a Coilralo(s) licGcd pBuatil to thc CrottElor's Licre lzw). <br />_l am exempt under B. & P.C. for this reason. <br />flo I o. <br />WORKERS' COMPENSATION <br />DECI,ARATION <br />I hereby affrm under penalty of pcrjury one of the following declarations: <br />_l have and will maintain a Certificate of Consent to Self-lnsure for workenl' comperuation, as provided for by Section 3700 of the <br />Labor Code, for the performance of the wort for which the pcrnrit is issued. <br />film"c and will minrain workm' compcmtior irurmce I rcquirrd by setion 3700 ofthc kbor Codc. for thc pcfomme of <br />'the'm* for which thie pqmit is i$!d. My work6' ompaBstioa immcc qic ad policy numba rc: <br />Policy <br />a (D <br />_l certi& that in the performance of the work for which this permit is issued. I shall not employ any person in any manner <br />so as to become subject to the worters'compensation laws of California, and agree that if I should become subject to the <br />workcrs' compensation provisions of Section 3700 of the labor Codc I slull. forthwilh comply with thosc provisions.. <br />WARNING: Failure to sccure workcrs'compcosation coverage is unlawful. and shall subjoct an anployer to criminal panltits and <br />civil fines up to one hundred thousand dollars ($100.000), in addition to the cost of compensation. &magcs as provided for the <br />Section 3076 of the Labor interest and attorney's fees.Z> <br />DECI"ARATION <br />I hereby affirm under penalty of perjury that I am licensed under p,rovision of Chaptcr 9 (commencing with Section 7000) of D0ision 3 <br />of the Business and Professions Code, and my license is in full force and effect. <br />License L t <br />",,", 'V>l L(4t)<,) <br />W <br />I hwby aflim unds peralty of pqjury thal thrc is 8 con$ruc{ion hoding agocy for thc pofomacc of thc work for which lhis pcrmit b <br />issucd (Se. 3097, Civ. C.). <br />l,endcr's Name: <br />Lcnilcr 's r\rltlr css. <br />APPLICANT DECLARATION <br />I hercby afnrm under penalty of pcrjury one of the following detlarations: <br />Demolition Permits-Asbestos Notification Fcderal Regulations (Title 40. Part6) <br />-Required <br />Letter of Notification <br />_l certi& that the federalregulations rcaarding asbestos removal are not applicable to this project. <br />with all City and County <br />and County to eflter upon thc <br />above msntioned property for inspection <br />Applicnnt or Agent <br />Permitee nArne <br />,",., {}lIvl. p <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />ArealStorm Drain <br />I nterceptor/ Cla rifier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />Main Drain/Pool Pipinq <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewer/Cap <br />Back FIow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release A tt ^f).ao <br />FINAL l,H15 lfl)AW&t WXI <br />Notes Remarks Etc. <br />--) <br />,,,.,, LI/ tt /)rl