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PLUMB!NG-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS ()lVNT'R BUILDI'R I)IiI,CARATIoN <br />I hcrcby rllirm undcr pcilalty of fcrjury lhat I rtrt cicnri liom lhc (i'nlriclors' Liccnsc l.arv lirr thc folkr$irg rcavrn (Scc.7o-ll 5 <br />Busincsr and l,rol'('\sion C(xlc)t Any City or C(ilnty \\tich rcqrircs a 1-..nril lo conslntcl. allcr. imprrlc. dcnxtlish or rcprir any <br />struclLtr.c. pri()r to il\ issuxtcc. al\() rcquircs thc ipplicint lbr \uch lErnril lo lllc r signcd slalcirnl lhat h( or \hc is liccnscd pursuant <br />k) thc pft)!i\i()ns oI tlrc Contrxcl()r's Liccnscd [-aw (Chrplcr 9. Coilril]cncing rvilh Scclirri 7(XX) ol t)ivisi()n -l ol'lhc Busincss xt(l <br />applicdntlirrnNrnrilsubjcctsthc ilpplicanlhilcivilpcnrllyofnolnr)rclhdnlj\chundrc(l(lollnrs(35(X)). <br />_1. ns {rwncr ol lhc prolErtv. or nry cnll)loyces wilh Nascs as thcir \olc conlfcn\ation. \'illtkr thc rok aml tlE struturc is not <br />thc p()ltrty lvho huilds or iml)rovc\ thcrq)n. ilkl who (l(rs such *ork hirn\cll or hcrsclfor lhr(rulh hi\ or hcr own cillpl()yccs <br />\xlc l. <br />_1. as owncr oflhc ptupcny. tnt cxclusivcly conlraclinS s ilh Iiccnscd coDlrtrclors h con\lnrcl lhc Pmjccl (Scc. 7(X4. Busincss <br />and Errlissir Codc: Thc Conlractor's Licensc [,aw docs nol npply lo an owncr oIpropcrly who huilds or irnprolcs lhcrcon. <br />and who contracts for such p(r.rccts with a Conlrnclo(s) liccnscd pursuanl lo lhc Conlrncktr's l,iccnsc Law). <br />-l <br />{ilIcxcnlil undcr Scclt)n-. Il & P.C-. Ibr lhis rcuson <br />Drte:-Orrncr: <br />]1!}8f,8&5:C0UPIINSATIAN <br />DECLARATION <br />I hcrcby alllrm undcr pcnahy of pcrjury one of thc following dcclaral ions: <br />_l havcandwill maintni[u(trlilicrteofC]onsc[lhSclf-lnsurcli,rworkcrs'compensalion.ils providcdforbyScctbn3Tmofthc <br />Lat{)r Cqlc. for lhc perfornuncc ofthc work for which thc pcrmit is issued. <br />_lharcandu,illmaintainworkcn'compensalioninsurancc.as rcquircdbyScclion-17(X)ofthclaborCodc.forlhcPctfornunccof <br />lhe work lir which lhis pcrmit is issuc{. My workcrs' conrpcnsalion insurancc canicr arxl grlicy tlutrlbcr ee: <br />Policy <br />_l cenify lhat in rhe pcrforrorcc of the work for which lhis Jrermit is irsued. I shall not employ 8ny Jrcrmn in any manrcr <br />m as to becom sub.ic<l to thc wotkss' omJrcnstion lsws of Califomia. and sgEc thal if t should bcrom subjtrl to tlE <br />worksi' comlEnsation provisions of Scrtion 3700 of lhe kbor Codc. I ihall. fonhwilh comply with tlFs Pmvisions.. <br />WARNINGI lrailurc lo $curc workcrs'comJrensalion covcrage is unlawful. and shall suhject 8n cmploycr to oimirul penaltics and <br />civil fincs up to ore hundrcd thoussnd dollars ($l(n.fin). <br />Scclion 3076 oflhc trbor Codc. inlcrcst and atlorrcy's fccs. <br />i0 addilion lo thc cosl of drnragcs as pr()vidcd li)r lhc <br />t <br />Appli(snt: <br />DIICLASAIIQN <br />('l' lhc []!\incs\ and Pn)lc\\i(,n\ (i{!c. an(l nty liccrsc is in lull li:rcc antl clli'ct. <br />Lir.ur.cl,rrr, t 6 LicctrscNuilrhcr: <br />o,,",9--J-qz=.2 2o- <br />W <br />I hcrchy {ffirm undcr tEnulty of pcrjury lhat thcrc is a conslruction hnding agcrcy for thc prforroncc of thc work for which this FErmil is <br />issucd (Scc. 3097. Civ. C.). <br />kndo's Narc: <br />- <br />Lcndcr's Arltlre'ss: <br />APPI ICAN'I DECLARA]'IoN <br />I ltru+,) xliirnr urilcr pcnnll) ol l)criury onc of thc lirlkrwing dcclaratirrrrs: <br />Dcmolirion l'crnrils-Arhcclos N(iliticalir)n Fcdcral Rcguhlions (l'illc.lo. I'rfl6) <br />-Rcquircd <br />l,cllcr of N(nillcilli(il] <br />ccnify that lhc fedcralrcgulations rcgeding {sbcslos remvaluc n(il spplicable lo this Projet. <br />ccnify thnl I havc rcad lhis applicalion and slalc lhal lhc at[vc wilh all Chy and Counly <br />and Counly to enter uFFn thc0nd St{tc Llws rclulinS lo building <br />mntioncd propcrty for inspcclion <br />ApplirilDl or A,lrnt <br />Pemite nrme { <br />D,k,2-ta'Z?- <br />UNDER GROUND <br />Waste & Vent Z//i/44/ <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq 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 Heater/Gas 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 tl <br />FINAL t4 l0 w F(KV,o\-*g <br />I tNotes, Remarks, Etc.I <br />4; <br />71t -4 <br />o,c, c c;\-l^'2-o7.'