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PLUMB!NG.!NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.GOMMENTS OWNER BUILDER DELCARATION <br />I hereby affrm undcr p.mhy of p€dury that I m exempt fmm the Contractors' Licensc Law for tlrc following remn (Se.7031.5 <br />Business aod Pmf6sion Codc): Any City or County which rcquircs a lEmit to @ndrud, altet imprcvg dmlish or rcJmir any <br />strocturc, prior to its iisarcc, also rcquircs thc applicant for wch pcmit to file a sigrcd statemcnt that tE or shc i! licensd pursant <br />to the pmvisions of thc Contractor's Licensed Law (Chapter 9, Commcncing wilh Scction 7000 of Division 3 of thc Busincss and <br />PpfessionsCode)orthath€orsh.hcxcmptthcrcfmmandthchdsisforrhcallcgedcxcmption. AnyviolationofSelionT03l.5byany <br />applicantforspcmitsubjctsthc appli@nttoscivilpcMhyofmlmorcthanfivehundrcddollars($500). <br />_1, as owner of thc rrmFerty, or my employes wilh wages as lh€ir sle compcnsation. will do the work atd tlE struhue is mt <br />intsrdcd or offcred for slc (Sc.7044, Busircss and Pmfessionr Code: 'l h. ConlEctor's Liccme Law docs mt apply lo an owM of <br />thc pmpny wln buildr or impmva ttssr1 ord who dod sch wort himsclf or hemlf or thrcugh hii or hcr own cmployecs, <br />providcd that ruch impmvmnts rc mt intcrdcd or offcrcd ftrr slc. lf, lnwwr, the building or impmvcrent is rld within onc )qr <br />ofcon{,letior! the C)wner Buildtr will have thc budcn ofpreving that he or shc did mt build or irpmvc thc pmp€rty for thc purfnse of <br />sh). <br />_1, as owrcr of thc pmpeny, am exclusively contracting with lice[sed contmclom to conilruct thc pmjcrct (Sec. 7044, Business <br />and PmfssionCodc:'lheContractor'sLicenseLawdoesnotapplytoanowncrofpropertywhobuildsorimprcvesthcreon. <br />and who contmcts for such pmjftts with a ConlEcto(s) licenscd puBuant to the Contractor's Licensc L6w). <br />-l <br />m cxcmpt undcr Setion-, B. & P.C. forthis twn. <br />Datc:_ <br />1I'ORKf, RS' COI\I PENSAl'ION!4UB{r0! <br />I herehy allirrn undcr penalty ofperlury one ofthe [olkrwing cleclarations: <br />_l havc arl will mainlniil a Cerlilicnte of Consent to Self-lnsure for rvorkers contpensalion, as pr)vi(led for hy Section l7(l(l of the <br />Lohor Code, fi)r lhe perfirrnunce ofthe work for which the pcmrit is issuetl. <br />fu/hnvc cnrl will nrarntarn rvorkers compensati()n iilsurnncc. ils requircd hy Section J700 oflhe t-ahor Code, for the perfonnance of <br />tte work lir q'hich this pennit is rsscd. My workers compensxlion insurance canier lml policy nunther are: <br />F) <br />Policy <br />-:-l ccnify lhat in thc pcrformmc of the work for which this permit is issucd, I shall mt cmploy any pcMn in any manrcr <br />m as to beore sbjct to th€ worteN' compensalion laws of Califomia, 0nd agrc that if I stnuld tEomc subjet to thc <br />workers'compensationpmvisionsofSection3T00oftheLaborCode,tshall,forthwithmmplywilhlhorcprcvisio[s.. <br />WARNING: failurc to sure wod(ca'compc[stion ovcmgc is unlawful, and shall subirct an mplolcr to simiml tEhhi6 and <br />cMl fincs up to orc hundred thousnd dollsB ($100,000), in addition lo the cost of compe[etion, damgcs as provided for the <br />Seclion.1076 Code, inlerest and aftorney's fees. <br />I <br />t)t(l,ARAIl()N <br />I hercby aflirm undcr pemlty of pcrjury thBt I am liccn*d under pmvision of Chaptq 9 (mmmncing with Sction 7000) of Divirion 3 <br />of thc Busircs and Pmfasions Codc, ard my licerk is in full forc ard cflcct. <br />1.71eo /l-iccnsc Nuurhrr: <br />Cotrlr{c(or: <br />W <br />I herchy affirnr under penalty of perjury that thtrc is a conil ruct ion lending rgency for the perfomancc of lhe qrrrk ftrr u'hich this pemit is <br />issued (Sec. 1097, Civ. C.). <br />l-ender's Nanre <br />Lender's Address: <br />APPLICAN'I DECLARA'I'ION <br />I lmby aflim under penally ofperjury one ofthe lirllowing declorations: <br />Demlilion Permits-Ashcstos Nolificalion l:edcral ReSulalionr ( lille 40. Pan6) <br />-Requircd <br />Lettcr of Notification <br />-l <br />cqaify thlt the federnl relrulations rcgardinSr asheslos renmval are not applicable lo this preject. <br />ff crnrfy that I have read lhrs apllication ard stale that the atnv. infonnal ion is cor(t. I alTe to comply u'ith nll Ciry an<l County <br />odinances nnd State Laws relating to huilding construction, and hereby authorize representatives orthis City and Counly to enter upon the <br />atnve mnlioncd pmperty for <br />Appllcant or Agent <br />Pernritee name (prlnt):t <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />I nterceptor/ Clarifier <br />TOP OUT I I tl lt Ir- l. <br />Waste & Vent 2-4i-r-lr t <br />Water Pipinq (drm ') qL+rJ-g-'1 <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 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 />Rouqh Plumbinq <br />Final Gas Test <br />Meter Release Ir <br />FINAL L !-70 \2qPfi 1s7rtrxt <br />Notes, Remarks, Etc. <br />,,,,, lfnfg"?D <br />LtNtrycinl