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PLUMBING.!NSPECTOR REGORD I <br />APPROVALS DATE ID/S!G COMMENTS OWN}]R BTIILDER DEI,CARA'I'ION <br />IhcrehyallirmunderpenaltyofpcrjurythattsDexernprfmmtheContraclors LicenseLawforthefollowirrgreasrn1Sc.7(l3lll! <br />llusiness arxl Pnrfession Code): Any City or Counly which rcquire a permit to conflrucl. altc. improrc, d€nt)lish or reTlcrt any <br />slruclure, prior lo ils issuance, also requires the applicant for such FEnnit to lilc a signed statctrcnt that hc or she is licensed purruan{' <br />ro lhe previsions ofthe Contractor's l,icensed Law (Chaplcr 9. Commencing with Section 7000 ofDivision J ofthe tsusiness andl <br />PmfessionsCode)orthatheorsheisexempllherefromandthebasisforlheallegedexemplion. AnyviolalionofSectionT03l.5hyany <br />af,plic.ntforapemilsuhj$tsthe applicantloacivilpenallyofil)lmorelhanlivehundreddollars(S500). <br />_1, as owner of the pmpeny, or my employees wilh wnges as their sle compcnsnl ion, q'ill do llE sod( arxl the strudw is mt <br />intemlal orofferedforsale{Se.7(N4,BusinessandProfessionsCode:'lhcConlraclor'sLicensel,awdoesnotrpplyt)anownerof <br />the pmpeny who builds or impreves lher@n. and who dos such work himselfor herselfor thnrugh his or her own enlpk)yees, <br />provided thal such impmlemnts 0re mt inlended or ofTerd lirr sle. lf, however. lhe buikling or impmvermnl is *rld within one leor <br />ofcompletio[ the Oivner Builder u'ill have the hurden ofprcung ltfl he or she did frl build or impro\e lhe pmpffy for lhc purtnc of <br />sle). <br />_1, as owner of the propeny, am exclusively contracting wilh licensed conlrack)m lo construcl thc lmj(l (Sec. 7044, Business <br />and PmfssionCode: lheContractor'sLicenseLawdoesnotnpplytoanownerofpropeflywhohuildsorimproveslhcreon, <br />and who contmcts lbr such pmjects with a Conlmck)(s) licensed pursuanl k) lhe Contraclor's License Law). <br />-lamexemplundcrseclion-.B'&P,C.forthisrex$n.Dete: ()h'nerl <br />E9SEBre9!!EI,!SAJ.!AN <br />DCCLARA'I'IoN <br />I hcrcby aIfirm undcr penalty ofpajury ore ofthe following d(larations: <br />_l have and will mintain a Cenificatc of Conrcnt to Sclf-lnsre for workrs' compenrtion, as pmvided for by Sction 3700 of thc <br />hhor Code, for thc pcrfomrcc of lhc work for which thc pmit is issucd. <br />_l have and will mainlain workers' compensa(ion insurance, as required by Section 3700 oflhe Labor Code, for the perfummce of <br />the work fur which this permit is comfensalion policy numher re: <br />Prrlicy <br />_l cenify thBt in the performnce of the work for which this permit is issucd. I shall no( employ sny person in sny manncr <br />s as to hecome subject to the workrs' compcnstion laws ofcalifomia, and Bgree lhat if I slnuld becom subject to the <br />workss' @mpenslion pmvisions of Scction 1700 of lhe Labor Codq I shall, forthwilh comply wilh tbs pmvisions.. <br />IVARNING: l:ailure to *cure workers'compensation covemSc is unlawlll. dnd shall subjecl an employer h fiiminnl peMhis and <br />civil fines up to one hundred thousand dollam ($100,000), in to the cosl of damages as provided for the <br />Seclion 3076 Code, inlereil and fees. <br />0 I <br />I'ECI AIIAI'IoN <br />I hercby aflirnr under penalty of perjury that I am liccnrcrl under provision ofchaplcr I (commcncing with Section 7000) of Division l <br />of the Business and Professions Co<le, and my licensc is in full lbrce and effect. <br />License Numbcr:<- <br />CONS'I'RUCl'ION LENDIN(; A(;DNCY <br />I hcrchy affirm undcr penfllty o f perjury that there is a construcl ion lending agency fur the perfornhncc of the work for lr'hich this lEnnit is <br />issued (Src. 1097. Civ. C.). <br />Lender's Nanre <br />Lender's Addrcss: <br />APPLICANT XIFCLANATION <br />I horby aflim undr pcnalty of perjury orc of the following dalmtions: <br />Demlition Pcrmit3-Aibcstos Nolification Fedcml Rcgulations (Title 40, Pan6) <br />-Required <br />Letlcr of No(ilicalion <br />_l certify lhd lhc fedcral regulations rcgarding asbeslos removal are not applicable to this prejcct. <br />-l <br />ccrtiry thd I havc rcsd this applicalion snd satc that th€ above infomtion is comt. I agrE to @mplywith all Cityand County <br />ordimnces aod Statc Laws rclating to huilding construction, ard reprcsenlativca oflhis City and Counly to cnlq u[nn thc <br />ahovc mentioned prepcrly for <br />Appllcant or Agent <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />lnterceptor/ Clarifier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Pipins <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOUSPA <br />P{rap/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 />Sanitarv Sewer/Cap <br />Back Flow Device <br />Rouqh Plumbinq <br />Final Gas Test <br />Meter Release dl <br />FINAL 7-220 *,ilLtdl <br />Notes Remarks Etc. <br />l'ermitce name (prlDl)' <br />,)*," f ro,fr 1