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PLUMBING.!NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER AUILI'ER Df,LCARATION <br />I hereby affirm undcr penalty ofpcrjury that I m cxempt frem lhe Conlractors' License Law for thc following rcamn (Sec.7031.5 <br />Business ord Pmfcssion Code): Any City or County which rcqufes s lmil to @trstruct, alt6, improvq d€molhh or E?air any <br />structurc, prior to its irssnce, al$ requires the applicanl for wch Jrmit to filc a signcd slalercnt that h€ or ihe is licenscd puNnnl <br />to the pmvisions of thc Contractor's Licensed Law (Chaptcr 9, Comeming wilh Section 7000 of Division 3 of lhc Bucincss and <br />Pmfcasions Codc) or that he or she is cxempt therefrom and the basis for thc alleged exemption. Any violalion ofs(tion 701 1.5 by Bny <br />applicantfor6pemilsubjectsthe applicanltoacivilpcmltyofnotmorclhanfivehundrcddollars($500). <br />_1, aB owncr of thc pmpe(y. or my employees with wagcs as thcir sle compcnsation, will do thc work and thc stnEtrc is mt <br />intcrdcd or offered for mlc (Sc.?044, Busircss and Pmfeseionq Codc: -l'h. Contr.clor's Licmsc kw dos ret apply lo an owrcr of <br />rhe pmlErty wtn buildr or in{rrcv* thmq aod wln &m sch wo* himsclf or hcrclf or thmugh his or hcr own cmployees, <br />providcd that such impmrcmnts m ml intcrded or oflered for mle. l[, lnwwr. thc building or irprovcmnt is sld within onc yw <br />of completioq thc Osrcr Builder will have thc hurdcn of pmving tha hc or shc dil mt buiH or inrpmrc thc pmpaty for thc pupr of <br />mlc). <br />_1, as owner of the pmperty, am exclusivcly contmcting wilh licensed contmclon lo onflrucl th€ pmj$t (Sec. 7044, Busires <br />and PmfrssionCode: lheContractor'sLiccnscLawdoesnolapplytoanownerofpropcrtywhobuildsorimpmvesthercon. <br />and who ontmcts for such pDjets with a Codmcto(s) lic.Ncd puNuant to lhc Codractor's Licenk Las). <br />-l <br />om cxempt undcr S(tion-. B. & P.C. for thi3 reosn. <br />l)ate: <br />IVORr(f, RS' COIUPENSAl'tON <br />DECLARATTON <br />I herehy affirm under penalty ofperjury orc ofthe following delamlioosl <br />_l havc and will maintain a Certificate of Consent to Selflrrure for workers' conrpenlation, as prcvidcd for hy Strtion 3700 of the <br />hbor Code, for thc perfomrcc of thc work for which lhe pcmit ir isilcd. <br />_l have and will mainlain workerg' compcnsalion insurance, as required by Scctiun 3?00 oflhc Lahor Code, for thc pcrfomance of <br />the work for which this pemil is issed. My workss' @mpcnstion insurarce carier ard Jrlicy numher uc: <br />WA 9a^9 G II'o I iet <br />_l cenify that in the performncc of the work for which this p.rmit is issued. I shall not employ any Jrcrson in any manner <br />m as to trom subjel lo thc Bortm'compcnqtion laws of Califomia. 6nd agrcc that if I slnuld becomc sbjet lo thc <br />wort6' smpcnsation pmvisions of Setion 3700 of the Latnr Codc. I shall, forthwilh $mply wilh thos pmvisions.. <br />WARNING: roilure to sue workeB'compenslion @veruge is unlawful. and shall suhjst an mplo,€r to siminal lEmhi.s and <br />civil fines up to one hundrcd thousond dollars ($l lhe cost ofcompensalion, damges as provided for lhc <br />Sation 3076 of Code, iilcrd and snorney's <br />4 q <br />I hcrchy aflirm uoder pcmlty of pcrjury that I m lienscd undcr povision of Choptq 9 (@mmming with Section 7000) of Division 3 <br />of thc Busincss and Pmfcssions Codc, and my liccnse is in full force and effet. <br />License <br />Date:cl <br />I hercby affirm undcr ;rmlty of pcrjury that thcre b s @rctruclion <br />isscd (S(. 3097, Civ. C.). <br />lbr thc psfonn nce of the u,ork for which lhis rrmil is <br />Lender's Name: <br />l.ender's Address: <br />APPLICANl' DI'CLARAI'I0N <br />I lm'hy allinn under pcnalty ofperjury onc ol the frrlkx ing declarrl irns' <br />Dcnr)lilion Pcrnrits-Asheslos Nolilicrtion Ijederal RcEulatft)ns ( l ille 40. Prd(r) <br />_licquirc(l l.ettcr of Notilication <br />-l <br />ceniry thal rhc fedeml .elulations rcBarding asbestos rcmval are nol applicable lo lhis prej.ct. <br />_l certiry thal I havc read lhis applical <br />ordimnces and Statc Laws GlatinS to bui <br />above mcnlioncd pmperty for inspection <br />thc ntnve inlbrtrr.lion is corect. I .8ree to comply with 0ll Cily {nd Counly <br />ard herehy autlnrize represnlatives ofthis Cily and County to enlE upon lhc <br />,\pplicntrl or,\grtrt <br />Pernritec nanre (prinl) <br />,,,"-{g[L <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 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 />Rough Plumbing <br />Fina! Gas Test <br />Meter Release I <br />FINAL dtaltu)Dftn/?,n #Yt <br />Notes, Remarks, Etc.I vl <br />tulr lrq