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PLUMBING.INSPECTOR RECORD <br />ID/SIG.COMMENTSAPPROVALSDATE <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Building Sewer <br />Area/Storm Drain <br />I nterceptor/ 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 />POOUSPA <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 />Rough Plumbing <br />Final Gas Test I <br />/MeterRelease J .,1 <br />FINAL L/ 1/71 ))b /-/u//L rOY <br />Notes, Remarks, Etc.I <br />o\\'NuR Ill'il.|)llR l)El.( ,,\RA Il()N <br />IherebynmrmunderpenaltyofpcrjurythatIamexemptlh)mthc('ontfttctors l,icense[.as'lirrthefollowingreav)n(Sec.7031.5 <br />Business and Profession Cale): Any City or County which requires a pcrnil lo conslrucl, aller. improve. rlentolish'i,r ,"pn,, nnyt <br />slructure,priork)its issuance,alsorequiresthealplicanlforsuchperrnitkrfileasrgnedstalemenl thathcorsheisliccntd pur;uart <br />Io lhe pmvisions ofthe ('ontractor's l,icensed l.aw (Chapter 9. Commcncing with Seclion 7000 of Dirision -1 ofthe Dusine{ aitl <br />Professions code) or that he or she is eiempl lherefrom and I he hasis tor th€ alleged exemPl bn' Any f iolal ion o f sst bn 7l)l I 5 h' iny <br />applicant for a pemit subjects the applicant lo a civil penallyofnot nmre lhan five hundred dollars (55001 , '(, <br />_1, ns owner of lhe pnrpeny, or my etnployees wilh wiges as lheir sole contpensation, will do the work and the structue is ml <br />intended orofl'eredforsle(Se.TO44.BusinessandProfessionsCode:'lhe(bntractor'sLicensel-awdosnolapplyloanoq'nerof <br />lhcpmntny wk)huildrorimprovstlrrqro,nmlwhrdoessuchuorkhimselforherselforIhnrughhisorhero$nemployecs, <br />provided that such improrcmenls are nol intemlcd oroflbsl firr sle. ll. howcver, llr huildirg or inlnrovetrent is sokl within one year <br />ofcomplelion, thc Cr{ner Builder will hlve the hurden ofpreving thal hc or she did ml buiki or impmve the pmFrty fi)r th€ lur[ns of <br />salc). <br />_1. fls owner of lhe pmpeny, am exclusively conlracliDg u'ilh licens<l conlrnclom lo conslrucl the pmjftt (S(. 7(X4, ltusiress <br />anl Pnrlission Code: 'l hc Co[lractor's License Law docs not apply to {n owner ofpropeny who huilcls or improves lhereon, <br />and wlro coillracls for such pmjills with a ('onlmcb(s) licensed Pursuanl h lhe Conlraclor's Licensc La*'). <br />_l am cxempl under B. & P.C. for lhis reason. <br />l)nte:()$iler <br />IvoRKERS' COillPf,NSA'l lON <br />D&g& 8AI!!)! <br />I herehy a lfirm untler pcmlty of perjury one ol l he folk)wing (leclar.l i(rns: <br />_l have nml will maintain a Certificate of Consenl to Selllnsure lirr workers' conlpensali(rn, as prrvided fur by Section 370o ol lhe <br />l-ntxrr Code. frrr lhe perlrrrrnancc ofthc sork lirr which lhe pcnlit is issued. <br />_lhavrnndwillmaintainworkers'comnensalioninsurancc,as requiredhySeclion3T00oftheLoborCode,firrlhepcrformanceof <br />theqrrrkf(rru'hichthispemilisis$ed.Myrvorkers comPensalioninsuralEecaricraftlFxllicynumherare: <br />Policy Number Expires: <br />_l cenify thar in the performance of the work for which this permit is isrued, I shall noI cmploy any pcmon in any mnnner <br />m as to hccomc wbjct lo the works' @mpcnetion laws of Califomia. and agrc lhat if I should hecom subjrct to thc <br />workem' compcnsation pmvisions of Sction 1700 of the Latnr Code, I shall, forthwith mmply with tlnrc pmvisions.. <br />WARNIN(;: l;ailure to wurc workem' <br />civil fincs up to one hundred thousand <br />is unlawful, and shall sbjcrt an mploltr to qimiml ,rroltiq and <br />in addition lo the cost ofcompcnsalio!, damages as provrded for lhe <br />t4og;tM APsetion 3076 ofthc Llhr Codc, inlercat and fes.,\44,T <br />CD <br />I bcrcby affrm under penalty of pcrjury that I am liccnsed undcr pmvision 9 (mmrencing with Setion 7000) of Division 3 <br />of the Business and Professions Codc, and my liccnse is in full forcc ard efTect <br />b icense Numtrr:Lo@,CTKTLiccmc <br />Dstc:r \,6t*'( B:t LI-DNA c-oW <br />I h.Eby amrm under fEmhy of pcrjury that <br />issucd (Src. 3097, Civ. C.). <br />isa lerding agercy for the pofirmrce of the work for *'hich this Jrmit is <br />Lender's Name: <br />Lehder's Addrccr: <br />ATfJ.ICANLI'ECLABAIIQN <br />I hoe$y afim under penalty of perjury one ofthe following declarations: <br />[)enmliton Permits-Asheslos Nolificalon l;ecleral Regulations ('l itle 40, Pan6) <br />-Required <br />l.elter ol'Notifi cfllion <br />with all City and County <br />and County lo cnltr uFrn lhc <br />Perniaee ti^ta YY MO55 <br />+lLsf ,? <br />ou., T lzfft? <br />?