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PLUMBING-INSPECTOR RECORD <br />APPROVALS DATE !D/SIG.COMMENTS OWNERBUILDERDELCARATION . <br />I hcrcby a{lirm undcr penalty of pcrjury thot I m cxcmpt fKrm the ConlractoN' Licnsc kw for thc following rcasn (54.7031 5 <br />Busincas and Prcfession Codc): Any City or County which rcquircs a Jrcrmit to onstruct, Elter. improrc. demlish or rcpair aiy <br />structrc. Fior to ils issuare. dm rcquircs the applicant for such permit to lilc 8 signed statcmnl lhat he or slE is lien$d pusatt <br />to thc lf,ovisions of thc Contretor's Lien$d kw (Chapts 9. Commercing wilh Sslion 7000 of Division 3 of thc Busircss an{ <br />Prcfcssions Code) or that he or shc is excmpt thcrcfrom ild thc h&sis for thc allcgcd cxcmption. Any violation of Sstion 70.1 I .5 by sny <br />applictrnt for a lrcmit subjsts thc applicant to I civil pemlty of not mre thsn fivc hundrcd dollars ($50o). <br />_1. as owncr of lhc propcrty. or nly employccs wilh wagcs ts lhcir sole conrpcnslti()n. s,illdo lhc work and lhc slnrcturc is not <br />irrtcrdcd orolTcrc(l l'or salc (Sec.70.14. Busincss and Proficssions Ccxlc: Thc Contraclor's Liccnsc [-aw does nol apply lo an orvncr of <br />lhc pnrpcrly who builcls or improvL's lhcrcon. and who does such work himsclf or hcrsclf or lhrough his or hcr orvn cntployccs. <br />providcd that such irnpnrvenrcnts arc not intcndcd or olli:red ltlr salc. lt. howcvcr. thc huilding or irnprovcrncnt is sold within onc ycar <br />of conrphtion. thc Owncr Buildcr will havc thc hurdcn of proving lhat hc or shc tlitl rxrt build or irnprovc thc propcrly ftrr thc purlxrsc of <br />sah). <br />-1. <br />asownero[the propcrty. anrcxclusivclyconlrrcting wilh liccnsctl contraclors to conslntcl lhc'projcct (Scc. 71A4. Busincss <br />and Pnrli:ssi<llrCoclc: 'l'hcCorrtractor'sLiccnsc[,awdocsnotapplyloanowrrcrot'propcrtywh<lbuildsorimprovesthcrcon. <br />arxl who conlracls ttrr such projccts with a Contractor(s) liccnscd pursuanl lo lhc Contraclor's Liccnsc Law). <br />-latttcxcmplundcrScction-.B.&P.C.t.orlhisrcasrrn. <br />fl6t6. (lr.,nar. <br />WORKERS' COMPENSATION <br />DECI ARATION <br />I hercby affirm under penalty of pcrjury onc of thc following declarations: <br />-l <br />havc and will maintain a Ccrtificale of Conscnt to Self-lnsurc for workers' compensation. as provided for by Section 3700 of thc <br />Labor Code. for the pcrfornrance of the work for which the Jrcrnrit is issued. <br />-l <br />havc and will maintain workcrs' compensalion insurance. as required by Scction 37fi) of lhc labor Codc. for thc performance of <br />thc work for which this prmit is issucd. My workcrs' com[rcnsalion insurancc carricr and plicy numbcr are: <br />Carricr: <br />Policv Number: Exoires: <br />_l ccrtify that in the pcrfornuncc of the work for which this pcrmit is issued. I shall not cmploy any person in any manncr <br />so os to bcconrc subject to thc workcrs' compcnsat ion laws of Culifornia. and agrcc that if I should bccome subjcct to the <br />workcrs' compcnsation provisions of Section 37fi) of thc lxtnr Code. I shall. forthwith comply wilh thosc provisions.. <br />WARNING: Failure to secure workcrs'compensation coverage is unlawful. and shall subject an employcr to criminal pcnalties and <br />civil fincs up to one hundrcd thousand dollars ($100,000). in addition to thc cost of comJrcnsation. damages as providcd for thc <br />Scction 3076 of the latnr Codc. intcrcst and attorncy's fees. <br />I ):r I r': <br />I ICENSED CONTRAC'I'OR <br />DECLARATION <br />I hcrcby aftirrn undcr pcnalty of pcrjury that I anr liccnscd urrdcr provision of Challtcr 9 (comrtrcrtcing with .Scclion 7000) ol'l)ivision 3 <br />of lhc Busincss and Profcssions Codc. and my liccrtsc is in full lorcc and eltcct. <br />License Class: License Number: <br />flolo. <br />W <br />I hcrchy affirm under Jrcnrlty of Frjury thst lhcrc is a construclion hnding agcncy for thc psformancc ofthc sork for which this Jrcrmit is <br />issucd (Scc. 3097, Civ. C.). <br />kndcr's Nam: <br />kndcr's Address: <br />Appl tclnl nrct.lR.lrloN <br />I lrrcby aflimr under pcnalty of prjury onc of thc following dcclarations: <br />Dcnmlition Pcrnrits-Asbcstos Nolification Fedcral Regulations (Titlc 40. Part6) <br />-Rcqu <br />ired Lcllcr of Notification <br />-l <br />ccrlify thit thc fcdcral rcgulations EgardinS asbcstos rcmvaluc nol applicablc to this pmjcct. <br />-l <br />ccnify that I hrvc rcad this application 8rd statc that thc atnvc infomllion is coret. I a8re to @mply with all City 8nd Counly <br />oKlinanccs and Stalc kws rchting to building construction. ild hcrcby authoria reprcsntstives ofthis Cily and County to cntcr utFn the <br />ahovc mntioned prcpcrly for inspcrtion purposs. <br />Applicant or Agent Signature: <br />I'erilrilN ilililrc (pritrll: <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf Ioor <br />Buildinq Sewer <br />ArealStorm Drain <br />I nterceptor/ CIarif ier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rouqh Water Heater <br />POOL/SPA <br />P-trao/Drain Line <br />[Vlain Drain/Pool Pipinq <br />Fill Line/Back Flow <br />Pool Heaterlcas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary SewerlCao <br />Back Flow Device <br />Rouqh Plumbinq <br />Final Gas Test T\ <br />Meter Release ,rt \l <br />FINAL la-lb.h D P)UI <br />EtcRemarks