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PLUMBING.INSPECTOR RECORD <br />APPROVALS DATE ID/S!G.COMMENTS OWNER BUILDER DELCARATION <br />I hercby aflirm undcr penalty of lErjury thal I m cxempl f.om lhe Contraclos' Licene law for the following rcawn (Sc.7031.5 <br />Business snd Profession Code): Any City or County which rcquires a 1rermil Io construct, altq, improve, demlish or rcpair any <br />structulc. prior to its issuance. ulso rcquires the applicut for such frcrmil to filc I signed statemnt that he or she is liccnscd pursuart <br />to thc prcvisions of thc Contractor's Liccnsd llw (Chapter 9. Commcncing with Setion 7000 of Division 3 of the Busincss md <br />Prcfcssions Code) or that he or she is cxcmpt thmfiom and thc basis for lhc sllcgcd exemplion. Any viol8tion of SBtion 703 I .5 by any <br />applicsnt for I pemit subjsts thc qpplicant lo s civil pcnalty of not mre than fivc hundred dolles (S500). <br />_1. as owncr of thc pmlErty, or my cmployees with wages as thcir sle compe nsation. will do the work ud lhc stnrtw ii nol <br />intcrdcd oroffercdforsle(Sa.T044.BusiressmdPrcfessionsCode:ThcContractor'sLicenscl:wdesnotapplytomowrcrof <br />thc ImtErty who boilds or irprcB themn. ard who dms $ch rcrk himself or hcrclf or lhmugh his or hcr own employccs. <br />provided that such imlrewmnts rc mt htcndcd oroffercd for slc. lf. howes. lhe buihing or itrprcremnt is $H wilhin onc )cU <br />ofcompletion. the Owncr Buihcr will haw thc burdcn ofproving lhat hc or shc did mt buiH or irprow the pmrErty for ttE purFDs of <br />sle). <br />_1. as owncr of thc lm]rcny. am cxclusively contracting eith lienscd contractoFlo mnsmcl thc treject (Str. 7044. Busincrs <br />and Profssion Codc: Thc Contractor's Licensc Law does nol apply to u owner of prolrfly who builds or improves lhcrcon. <br />and who contmcts for such prcjccls wilh a Contmclor(s) liccnsed pursuanl to lhc Contractor's License Lsw). <br />IamcxcmDlunderScction-.B.&P.c.forlhisrcason- <br />Dsle: o*ner: <br />IUI}8trEBLCIJIISENSAIIAN <br />D&CI"A8AII9N <br />I hcrchy al firrn undcr pcnalty of Jrcrjury 0c of thc lolkrwing dcclurat ions: <br />_l hrvcadwill nuinlilin{CcnitlcatcofConsc[tloSclLlnsurclirrworkcrs'conrpcnsation,x\ providcdlorhyScclion.lT(x)ofthc <br />Lak)r Codc. for thc pcrli)rnuncc ol lhc work for which Ihc frcrmit is issued. <br />_l havc and will Nninlrin porkcrs' c(,nrFEnsattrn insurancc. as rt'quircd hy Scctkn 37(X) oflhc libor Codc. for thc pcrforruncc of <br />thc work li)r which this pcrmil is issuLd. My workcrs' compcn\rli([ insurancc crricr ud [mlicy numbcr arc: <br />Policv Nunrhcr: Exoircs: <br />_l ccrtify lhat in thc FErformrce of lhc work for which this pcrmil is issucd. I shall nol cmploy any pcrson in any manrcr <br />so !s to bccore subjcct lo thc work6s'compcnsalion laws ofCalifornia. and agrcc lhflt ifl should becore subjcct to thc <br />workcrs' compcnsation provisions ofSNtion 37fl) ofthc ktnr Codc. I sh{ll. fonhwilh comply with thorc provisions.. <br />WARNING: Failure to scuc worken'compctrsalion ovemgc is unlawful. and shall subjcct an employer to cimiml [EEltLs and <br />civil fincs up to onc hundrcd thousand dollus ($100.000), in addilion to thc cost of compcnsation, damgcs as provided for the <br />Scction 3076 ofthc Labor Codc, intcrest {nd allorrey's fces. <br />I ICENSI.]I) CON'TR,IC'TOR <br />DIICI,AIITIIION <br />o! thc llu\iDc\\ ilrtrl lt('lc\\i()trs ('(xlc. xn(l rtv licunsc is in ltrll {ircc uild cllccl. <br />Licensc L'lussr-Liccnsc Numhcr: <br />I )illr (inlril(l(,r <br />CONS'TRUC'TI(IN LIJNDING AGI.INCI' <br />i\\ucd (Scc. .1097. ( iv. ('.). <br />lrndcr's Nam: <br />Lcndcr's Addrcss: <br />AfILISANLDECI,AEAIII'N <br />I M,y amm under pcnahy of pcrjury onc of thc following dcclarations: <br />Dcmolition Pcrmits-Ashcstos Notificulion Fcdcral Rcgulations (Tillc 40. Pm6) <br />-Rcquircd <br />klter of Notilicalion <br />-l <br />ccrtify that the federal regulations rcgardinS asbestos rcmval m not applicablc to this pojet. <br />_l ccnily thut I hlvc rca(l lhis afplicirlk)n and slrlc lhnl lhc ah)vc itrlbrtralion is corrcct. I agrN k) comply wilh lll City and Counly <br />rlnr'c trrcDli()ncd prol--fly li)r inspcclr)n purposc\. <br />Applicatra or Agrot <br />Pemitee nnme (print): _ <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildino Sewer <br />Area/Storm Drain <br />I nterceptor/ Clarif 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-trap/Drain Line <br />Main Drain/Pool Piping <br />Fill Line/Back Flow <br />Pool HeateriGas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewer/Cap <br />Back Flow Device <br />Rouqh Plumbinq <br />Final Gas Test <br />Meter Release tt <br />FINAL 7fr40u rtu/a 'Sa ?K <br />Notes, Remarks, Etc <br />I)alr: ,\ppli(xnl: