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PLU M BI NG{ NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.GOMMENTS Owna-Buil&r Dclraim <br />I hmby afiim undr pcrslty of Fjury thd I m ilmpt fm thc Cdtst@' Licalc ke for thc follwing rufi (G.7031.5 Burin* <br />md Prefoio Codc): Any City a Centy rhich rcquiu r Fmit to ffrtrud, ah6, imprcvc. dcrnolish c rcpeir uy structurc, pritr to its <br />iswcq also rcqgiH thc ryplimt fc such Ftnit to ,ilc 8 dFGd trdqmt thlt hc a rhc is li6r.d lusmr to fic Fovirios of rhc <br />Cotrrro's Limcd Lrw (Chapa6 9. Cmtlwing with Setid 70oo of Divirio 3 of thc Buins md Prcfeim Codc) a tha hc c <br />shc is cxmB thdfrom ud thc brsir fc thc rllcgcd aoprim .Any violerim of Scrim 7031.5 by uy applimt fa r pcmh subjcB thc <br />applicut to r civil pcnolty of no tre thu fivc hu&cd dolln ($50O). <br />_1, s ma of ttc propcny, c my oployo wirh wqo u thcir mlc mFnstio, will do 6c wort md thc ltrutw it nor iniadcd <br />c offcrcd fc salc ( Sc.7O44, Buine ud Ptofsim Codc: Thc Cmmdc't Liw lry du not 4dy to u ma of thc prqcrty <br />who buil& c impova thcm, md who dc ruch wst hirelf q hmlf c thrugh hir r hr m mploya, Fovidcd thrl such <br />imprcvmts re not inmdcd q offcrt{ fu :alc. If. hwwa, thc building o imprcmot ir rcld within mc yca of Mplctim, thc <br />Oms-Buildo will havc thc burdcn of proying thu hc c shc nrt build q imprcrc fq thc prposc of slc). <br />_1, u wna of thc propcrty, m cxcluivcly cmtrrting with limsrd mrelG lo ffiltuct thc prcjEt ( 56. 7044, BuinBr ud <br />Prcfasio Codc: Thc Cmtrcts'r Li6s [iv dc no ryply Io u oma of prcgcty who builds a imFovc th6m . ud who <br />cmtrets for such prcj@E eith a Cmtrrcto(s) limscd punmt to thc Cotretor's Licosc Lav ) <br />_l am exempt under Section <br />Date: <br />& P C. for this reason <br />Owner: <br />W <br />I hftby afiim un&r pendty of Frjury dc of thc follilinS doclmtios: <br />_l havc ad will mintain a Csrifietc of Cmot ro SclfJn:m fa wo*s' cmpco$lim. r povidcd fr by Sccrio 3700 of thc <br />liba Codc, ftr thc pcrfme of thc wqk fq which thc Frnit ir isucd. <br />r'_l hsvc od will mrintain watm' cmpca$tim itrrrue. s rcquircd by Sctim 3700 of thc Labc Codc, fff thc Frfme of thc <br />work for which.this fqmit is issued My workcrs' compensation insurance ciurier and policy <br />carrier \) lrtl ('IlYlL['i[l :Jtr, -. 1{,.'i..,- <br />numhr are: <br />poricy *,-*, ht-, L-; [ [ ] 'i '*: ri ( - f,/ <br />Expires <br />(This section need not bc completed if the permit is for One hun&ed dollars l$1001 or lcss) <br />I <br />in any manner so as to <br />thc workers' <br />\ <br />WARNING. Failw to rcurc worto' mFrraim ovcmgc ir unlewfnl, ud rhall :u[cr o mployr to riminal pcf,altic ild civil <br />fina up to oc hudred thowd dolln (t100.000),in ldditio to thc cqt of mpcroarim, &mags r providcd fs thc Sctio 1076 of <br />thc Lsbor Codc, intmt ud anmcy's fc. <br />@ <br />I hwby rffim unda pcnalty of pcrjury thrt I m licascd unds provilifi of Ctaptd 9 (comMcing with Sfttio 7000) of Division ! of <br />the Business and Code, and my liccnse is in full force and cffect.)tr <br />Liccnse <br />Date: <br />Liccnse Numbcr <br />a '3 <br />W <br />I hmby elfim u&r padty of pajury that thc ir r mrtnrcrio lmdiry qorcy fc thc Ffm of rhc wak fa vtich thi! Frrit is <br />isurd (Se. !(x)7, Civ. C.). <br />lmd6'rNm: <br />Lender's Address: <br />APPLICANT'S DECLARATION <br />Demolition Permits-Asbcstos Notification Federal Regulations (Title 40. Part 6) <br />_ Required Letter of Notification <br />_l certify that the federal regulations regarding asbcstos removal are not applicable to this project <br />-.-letrtifj-that I have read this application and state that the abovc information is correct I agree to with all City and County <br />ordinances and State Laws relating to building construction. and hereby authorize representatives of this and <br />above mcntioned propcrty for inspcction purposes <br />2 2u <br />2 <br />Lt <br />\ <br />,teelic{q(scnt <br />Grr Q--Qs <br />Date <br />lo enter upon the <br />UNDER GROUND <br />Waste & Vent <br />Water-Underfloor <br />Gas-Underfloor <br />Building Sewer <br />ArealStorm Drain <br />lnterceptor/ Clarifier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Pipeing <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOUSPA <br />P-trap/Drain Line <br />Main Drain/Pool Piping <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Misc <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewer/Cap <br />Back Flow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release <br />FINAL <br />Notes, Remarks, Etc.a? <br />oLl -og-4N6 <br />Pfu <br />in the performance of the work fr which this is issued, I shall not cmploy any <br />to the workelT ' <br />Labor Code, I shall,comply with.those <br />Date._ <br />ll_+Ws