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PLUMBING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMTJIENTS OWNER BUILDER DELCARATION <br />I hscby affm unda p@8lty of Frjury thar I m crcmpt from thc ContractoB' LicGc L8w for thc fotlowing rwo (Se.7031.5 <br />Buinqs and Prcfesion Codc): Any City or County which rcquir6 a pqmit to sDstruct. aha, imprcvq dorolis& or rqab u1v <br />structuc, pdor to its issuoce. also rcquire thc sppticet for such pcrmit to filc a signcd statm@t that hctr she b licoed puruari <br />to thc provisioB of thc Cootretor's Licensed Law (Chapto 9, Comocirg with Setion 7000 of Division 3 of thc Buine md <br />Prcfcssiom Codc) or that hc or shc is qqnpt thocfrom sd thc basis for thc allcScd qmption. Any violation of SBtbn 7031.5 by my <br />applicet for a pqmit subjets thc applicatrt to a civil pcoalty of oot morc the fivc hundrcd dollffi ($500). <br />-[. <br />I om6 of thc popety, or my mployu with wagc r th.t sle compqMtion. will do thc work ad tlrc sfirrtuc b not <br />ird6d or offacd for sale (Se.7044, Busins ild PrcfsioE Codq Thc Contraclor's LicGc Law do6 not apply to il osnd of <br />thc ptopqty who builds or impove thqoq ud who doe such wrk himsclf or hmelf or thrcugh his or ho om mployce. <br />provided that such imprcvmots m not intmded or ollqcd for slc lf, howwq, thc building or imprcvmmt is rcld within onc yw <br />ofcomplaion thc Orvna Buildq will have thc hrden ofproving lhd hc or she did nol tuild or improvc thc prcpqty for the purpos of <br />sle). <br />-1, <br />6 oms of thc propsty. m cxcluivcly contncling wilh licscd contracloE lo co6tBci tlE projct (S*. 7044. Buine <br />ed Prcfosion Codc: Thc Contraclor's LicGc Law doc not apply lo e omq of prcpqty who builds or improvG thq@n. <br />md who omncls for such prcj{ts with 8 Contracto(s) licmscd pmun to thc Contractor's Liccre Law). <br />-l <br />m cx@pt udq Setion-. B. & P.C. for this r@o. <br />Onn"r'@ <br />I hqeby aflm unde penalty ofpcjury one <br />- woRElAf coMPENsATroN <br />TIiCIABAIION <br />of the follorving deluations: <br />-l <br />havc rd will mintain 8 Cdificatc of Comt to Sclf-lrourc for rcrkc' omposation, re povided for by Sction 3?00 of thc <br />labo Codc. for thc pqfoffic of thc wolt for which thc pqmit b isucd. <br />-l <br />havc ad will mainlain work6' compcNation iBllffic, r rcquircd by Scrioo 3700 of tlE tabor Codc, for thc pqfomcc of <br />tha work for which thb pomil b isucd My worke' ompqsaion iroumc wia and policy numbo rc: <br />c.;-,Avu/e* tl)al-io,-v^l T-€orcvrCo Q=o . <br />poticyNumbq: 7 booo l5 ?o I I L-l Expir6. <br />-t <br />certiry thd in the psforunce of the work for which lhis pamit is issued. I shall oot mploy ey pqson in my mmns <br />$ 6 to bccomc subjet to thc wort6' compqtsation laws of Califomia ed agrc that if I should bccomc aubj(t to thc <br />worko' compqstion prcvisioro of Section 3700 of thc t bor Codq I slull. forthwith comply with tho$ prcvisioN.. <br />WARNING: Failuc to suc worko' compcnsdion covqage is unlawful. ed shall subj€l I mploF to qiminal pquhics ud <br />civil fua up to onc hundrcd lhownd dollss (S100.000), in addition to the cost of compcrution. damage s providcd for thc <br />Sation 3076 of thc t bor Codc itrtocg ud anomey's fc6. <br />I )r tc::-lz.t-l t1 <br />T r <br />I hwby affm undo poalty of perjury that I m licmsed 9 (commcing with Sation 7000) of Division 3 <br />Numbs: <br />I hrcby affm undo poalty of ptrjury that thtrc is a construction loding agmcy for thc psfomancc of the work for which this pqrnit is <br />issued (Se. 3097. Civ. C.). <br />lf,nds's Nme: <br />Lodq's Addrs: <br />APPLICANT DECI,A.R,ATION <br />I ho*y atrnu uoda poalty of pojury one of thc following deluatioru: <br />Demolition Pmils-Asb6tos Notification Fcd6al Rcgulstioos (Tillc 40, Pan6) <br />Roi<ed Lcttcr of Notilication <br />'6@)r rn^n he fcderat rc!ularions regu<ling mlxsr.s rcrnovat arc nor applicablc ro rhis projsl <br />-l <br />cqtiry tha( I havc rad this applicalion and statc that thc abovc infomation is concct. I agc lo comply with all City ud County <br />ordinec6 ed Statc kws rclating to building coBirucrion. ,nd hcby authorir rcprMlativc of this City md County to ot6 uJx)n thc <br />above motioned prcpqty for irepcrion purpose. <br />Applicana or Agml o"r", 1l%l11I' <br />Pemits nrmc (print): <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />I nterceptor/ Cla rifier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOL/SPA <br />Ptrap/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 />Rough Plumbing <br />Final Gas Test ']/z* t)rLc-I r7 <br />Meter Retease J <br />FINAL b-1 -tO Q-cts N e o*7 +2n <br />Notes, Remarks, Etc. <br />lZt-B - Dt*t*t- Jlr.I il*<m- 2-1-+rttn,rut*Lt tz*<.l,yl.^* JLrtr-t1 '?plt,[.*., bdu ?-i-O 9-/tlz Diii6)t <br />o"",'?lz-cltl <br />of the Buins od Profeioro Code. ad my licmc is in full forcc md effet. <br />liwcrm,6 <br />D,.", -tlz_Ll11 <br />.l <br />I <br />I