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PLUMB!NG.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OIVNER BUILI)I:R DEI,CARATION <br />IherehyllllrDundcrrcilrltyofp(riurylhatIuncrcillptlromthcContractors l-iccnscljwli)rlhclblk)Ningrca\onlscc.70]l.5 <br />Burincss and [,rofcssirrn Crxlc): Aily ('ity or C()unty which rcquircs a fErnlil k) conslrucl. {llcr. inUrovc. dcntolish or rcpair rrty <br />structurc.pri()rtoil\ issuilncc.llsorc<luhcsthcapplicintli)rsuchlrrnrilblilca\i8ncdslrlcilrctrl lhillhcorshcisliccnscd pursuant <br />k) lhc provist)ns of thc Coiltrick)r'\ l-ict'nscd I-a\' (Chnflcr 9. Conrrcncing t'ilh Scclioi 7(XX) ol I)ili\ion .l ol lhc Ru\inlsc and <br />l'rol'cssionsCt)dc)orlhdthcorrhciscxcnrptthcrcfronrandthcbrsisforthcallcgcrlcrcntplir'[ AnyYiohli([(,fScctrrn703l.5hyany <br />rpplicxnltorrpcrmilsubjcclsthc applicanlk)ilcivilfcnxllyofnotnx)rcthilill'i!chun,lrc(l(l(,llnr\l\5{)tl). ' <br />\rlc). <br />ilnd $'ho coltrrct\ li,r srrch projccts wilh r (i)rilrncknls) liccilscd pur\nrnl kr lhc Conlrxcloi\ l-iccn\c l.a$'). <br />l!trtcxcn|Dtundcrscclit,n-.B.&P.C,lb'lhisIcason. <br />Owner: <br />}}I)BSEELCAIIIENSA.IIQN <br />DECLARATION <br />I hcrcby affirm undct pcrjury onc ofthc following declaralions: <br />_l have rurd r('crtillcalcol'(i)nscilll(tScll:1il\urclirrul)rkcrs'conrl)cn\illi(nr.rs pr['itlcrllorhySccli()tr.17(x)rtllhc <br />l-rlxrr lhe pcrformmc of lhc work for which thc pcrnrit is issucd. <br />and will mainlsin workers' comlrcnsation insurancc, as rcquired by Scclion 3700 oflhe kbor Cbde. for lhc pcrformncc of <br />work for which this pcrmil is issucd. My workcrs' conrpcnsation insurancc caricr 8nd fxrlicy numtEr trc: <br /><L,A<,E*^a <br />Puli"y Nrrrb"r, lrrpir"*,rlr/zr <br />I ccrlily thit ii lhc pcrli)rilrncc ol lhc $r)rk li{ which lhi\ l)crnril is issucd. I shall nol cntlrk)y iny pcrson in iny nhn[cr <br />so as to ht'conrc suhjcct lo thc wotkcrs'c()nrpcnsrlion lnws ofCalifornix. and ngrcc lhat il l sh()ukl ltcr)nt \uhjccl k, lhc <br />WARNING: Frilurc to ecurc workcrs'conrFnsation covcragc is unlawful. and shall suhjNt an cmploycr lo oimin0l frcnnllics and <br />civil fincs up lo one hundrcd thousund dollurs m.000). in dddilion to thc cost of compcnsation. domgcs as providcd for lhe <br />Section 3076 ofthc latx)r Code. intercst l'ccs. <br />r)are: l,Sfr- <br />I)t,.( 1.,\lt.\ l lo\ <br />of thc Rusiicss ard l'rolc\siols Codc. an(l ilry liccnsc is ir full li)rcc and cflicl. <br />4 o <br />I hcrcby allirnt unrlcr pcnxlly of pcrjtrry lhnl thcrc <br />issucd (Scc. 3097. Civ. C-.). <br />Lcndcr's Nantc: <br />hnding agcncy for thc pcrtirrnrancc oflhc work lbr which this pcrmit is <br />[:ndcr's Addrcss: <br />APPLICAN'I DICI,ARATION <br />I lf,rby allinil undcr pcnulty ol pc4ury oilc oI lhc lolk)wilg dcclnrnlions: <br />Dcnblition ['crilrit\-A\hc\t(,\ N(ilificrti(]n licdcrul Rcgulaliotrs (Tillc.l0. Pan(]) <br />_Rcquircd [-cltcr of Noliliculion <br />-l <br />cerlify lhal the fcdcral rcgulations rcgarding asbcslos rcmval are f,ot applicable lo lhis PmjNt. <br />I rcad this applicetion arxl strte thal lhe {tove informlion is cor(1. I agxe lo omply with lll Cily and Counly <br />ordinanccs ttws rchling lo buiHing consfuclion. afld hcreby aulhorize rcprcsntolivcs oflhis Cilysnd Counly lo cnts ulDn tlE <br />atxrvc <br />Applicant AEenl _ Dale:I <br />J'cmrilee nailte <br />,br irspcction <br />t <br />2 s).o <br />UNDER GROUND <br />Waste & Vent P/;oi,zo O/on <br />Water-Under floor f-" I <br />Gas-Underfloor <br />Buildino Sewer <br />Area/Storm Drain <br />lnterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Piping <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 Pipinq <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 Z./t e/ro /Zr zU <br />Final Gas Test / <br />Meter Release <br />FINAL 3l g,/2a EZrs il€,.''*Q 14 <br />Notes, Remarks, Etc.