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PL UMBING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DETTARATION <br />I hccby affm unda pcnalty of pcrjury thal I m dmpt ftom thc Contractor' Liccre Law for thc following Iwn (Sc.7031.5 <br />Buin6s ,nd Prcfeion Codc): Any City or County which rcquiG 8 p6mit to onstruct. alta. imprcvq danolish or rcpair oy <br />structurc. prior to its isuucq also rcquirc thc applicot for such permit to filc a signcd statmmt thst hc or shc b licoscd puuut <br />to thc provisiom of thc Contractor's Lhascd Law (Chaptq 9. Comocing wirh Setion 7000 of Divishn 3 of the Buins ud <br />Prcfsions Codc) or that hc or shc i! cxmpt th@from ud the bosis for thc allcgod €xmpion. Any violation of Setion 7031.5 by my <br />applicant for a pcmit subjcts thc ap,plicut to a civil pcmlty of not morc thu fivc hun&cd dollus ($500). <br />_1, as owner of the property. or my employes with wages as their sole compensation, wi[ do the work and the stnrcture is not <br />intendcd or offered for sale (Sa.7O44, Business and hofcssions Code: The Contraoor's License law does not apply lo an owner of <br />the property who builds or improvcs thereon. and who does such wor* himself or hcrself or through his or her own employees. <br />provided that such improvonents tre not intendcd oroflbod for sale. I[, howevcr. the building or irnprovernent is rcH within one ]€ar <br />of complaion, the Ovrncr Builder will have the burdcn of proving tha he or she did not build or improve the propcty for thc purposcof <br />sale). <br />_1. as owner of thc property. am exclusively contracting with liccnsed contraclon to constnrct the project (Sec. 7044, Business <br />and Prof€ssbn Code: The Contractor's License Law does not apply to an owner of propcrty who builds or improves thereon. <br />and who contracts for such projeds with a Contraao(s) licansed puniuant to thc Contractor's License l-aw). <br />_l am exempt under ts. & P.C. for this reason. <br />flola. <br />WORKf,RSI COMPENSATION <br />DECIAEAIION <br />t,hcby alfim unda lmalty of pqjury onc of thc following deluatioB: <br />/-lhwcuAwitlmintsinaCcatificatcofcoMttosclfJmdrcforworkc'compcnsation.a providcdforbySetion3T00ofthc' tabor Codc for thc paformcc of thc wrt for which lhc pqmit b isuc{. <br />. fl havc and will maintain worlm' compcruation irouucc, r rcquircd by Sarion 37OO of thc trbor Codc. for thc pqforrwc of' thc work for which this pqmit is isuod My work6' ompcnsation iroumcc cmiq and policy numbc m: <br />lo ut'?-l I <br />_l certi& that in the perfonnance 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'compersation laws of California, and agree that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code. I shall. forthwith comply with those provisions.. <br />WARNING: Failure to secure workers' compensation coverage is unlarvful. and shall subject an onployer to criminal penalties and <br />civil frnes up to one hundred thousand dollars ($100.000), in addition to the cos of as provided for the <br />Section 3076 of the labor Code, interest and-{o,r",17' {' Ld <br />DIiCI,ARA'I'ION <br />I hereby aflirm under penalty of perjury that I am licensod under provision of Chapto 9 (commencing with Section 7000) of Division 3 <br />of the Business and Professions Code, and my liccnse is in full force and cffect. <br />,r^*, ( Lb License\S <br />CONSTR,UCTION LENDTNC ACENCY <br />I hrcby aflirm unda pcnalty of pcrjury tha thrc is a comtruction knding ag,6cy for thc pgfommc€ of thc work for which this Fnit b <br />issued (Se. 3097, Civ. C.). <br />Lendcr's Name: <br />l,endcr's Ad&ess: <br />APPLICANT DECLARATION <br />I hereby affirm under penalty of perjury one of the follorving declarations: <br />Demolition Pennits-Asbestos Notification Federal Regulations (Title 40. Pan6) <br />_Required Letter of Notification <br />are not applicable to this projcct. <br />is corret. I agrc to comply with all City and County <br />represcntatives of this city and county to enter upon the <br />above mentioned property for <br />Applicnnt or Agenl <br />purposes. <br />lu-Lo <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor lu/oQ KR n <br />Gas-Underfloor <br />Building Sewer <br />Area/Storm Drain <br />I nterceptor/ Clarifier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test ( <br />Rouqh 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 Flow Device <br />Roush Plumbins <br />Fina! Gas Test <br />Meter Release =l <br />FINAL il flrc- / S,a/z rtoS zv <br />Notes, Remarks, Etc. <br />o1 <br />Owner: <br />abovc <br />Permitee name (print):_