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PLUMBING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS <br />UNDER GROUND A <br />Waste & Vent '?'15.ru Ufu/& <br />Water-Under floor <br />Gas-Underfloor <br />Building Sewer <br />Area/Storm Drain <br />! nterceptor/ Clarifier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />It/ain 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 SewerlCao <br />Back Flow Device <br />Roush Plumbinq <br />Final Gas Test <br />Meter Release l_/nt <br />-s)FINAL <br />Rema Etc. <br />I 0 <br />OWNERBUTLDERDELCARATION <br />-I hscby aflirrn unds pcnalry of pcrjury that I m cxcmpt from the Contraclon' Licffc taw for thc following rcmn (Sc.7dJ <br />Buins od Prof*ion Codc): Atry City or County which requiro a pannit to snstrucl, altc. improvc donolish or tcaair al! <br />structue, prior to its isumce. alm rcquic the applicant for such pemit to 6lc a signcd statmot tha hc or shc is licmsal pmufit <br />to thc EovisioN of the Contractor's Liccnscd kw (ChaF6 9. Commcncing with Sation 7000 of Division 3 of thc Businx ad <br />Profc$ionsCode)orthalh€orsheiscxemptthsefrotnudthcbssisforlheallcgedexempion. AnyviolationofSetionT03l.5by3rny <br />applicantforapmitsubjetsthc applicantto.civilpoaltyofnotmorcthufivchundrcddollm($500). <br />_1. ro omq of thc properry. or my mplole with waga u thcir $le compomtion. will do the wort ud lhc snrclw b rct <br />intqdcd oroflsql for slc (Sa.7044. Busins dd ProfsioN Code: Thc Contractor's l,icme law doc not apply to m owntr of <br />thcprotmy whobuil&orimprcstluon.andwhodmsuchrw*himsclforhmlforthrcughhisorhaomcmploye. <br />providcd that such improvmmts rc rct intodcd or orqed for slc. l[ howwq. thc building or imtrovment is mld within onc ya <br />ofcompktion. thc Orvne Buikl,q will have thc hrdo ofpoving tha hc or strc did not hriH or impmve thc popoty for thc grposof <br />slc). <br />_1. 6 omer of Ihc propsty. dn cxclsivclycontracting wilh licoscd contracloE to snstruct thc projst (Ss. 7044. Bsins <br />ud Proftssbn Codc: Thc Contractor's Liccnsc Law do6 nol apply to il owns ofpropcny who builds or improv6 th6@n. <br />and who contncts for such prcjets whh a Contrrcto(s) licosed pun@l to thc Contractor's Liccme Law). <br />-l <br />m cxempt unds Sction-. B. & P.c. forthis llen. <br />hotn. <br />WORKERS' COMPENSATION <br />DFCLARATION <br />I hereby affrm under pcnalty of ffiury one of the following declarations: <br />_I have and will maintain a Ccrtificate of Conscnt to Self-lrsure for workers'comperrsation. as providod for by Section 3700 of the <br />Labor Code, for the performance of the work for which the permit is issued. <br />_l have and will maintain workers' compensation insurance, as required by Section <br />the work for which this permit is issued My workcrs' compcnsation insurance carrier <br />Carrier: fe /r / eot-- <br />Policy 007 d Z <br />_l certi& that in the pcrformance of the work for which this pcrmit is issued. I shall not ernploy any pcrson in any manner <br />so as to become subject to the work€rs'compensation 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 wilh those provisions.. <br />WARNING: Failure to sccure workers' compensation coverage is unlawful. and shall <br />3700 of the Labor Code. for the performance of <br />and policy number are: <br />subject an anployer to criminal penahies and <br />compensation. damages as provided for thecivil fines up to one hundred thousand dollars ($100.000). in <br />Section -j076 of the interest and attorney's fees. <br />Z ZO <br />I hereby aflinn under penalty of perjury that I am licenscd under <br />of the Business and Professions Code. and my license is in full force and efhct. <br />f3{ <br />9 (commencing with Section 7000) of Division 3 <br />the cost of <br />0a7az 7 <br />Licerse Class: <br />Dete:/2 <br />W <br />I h@by amnn unds penahy of perjury that thae is 8 corutruction lc{ding agocy for the pcfol1mcc of the work for which this pqrnit b <br />issuct (Se. -1097. Civ. C.). <br />Lender's Name: <br />Lender's Address: <br />APPLICANT DECLI\RATION <br />I hs,eby affinn under penalty of perjury one of the following declarations: <br />Demolition Pcrmits-Asbestos Notification Federal Regulations (Title 40. Part6) <br />0 F*tred <br />Lat er o r Notifi cat ion <br />_l ccrti& that thc Heral regulations rcgarding asbestos removalare not applicable to this project. <br />--l <br />certi$ that I have read this application and state that the above information is correct. I agree to comply with all City and County <br />ordinances and State Laws relating to and hereby authorize representatives of this City and County to entcr upon the <br />above mcntioned property for Z //< "tApplicant or Agent <br />Permitee /Vr* <br />t .I <br />Owner: <br />/ <br />faffi <br />It&ordPlt6/2e fq v\ <br />vkofr