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APPROVALS DATE
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Buildinq Sewer
<br />Area/Storm Drain
<br />Interceptor/ Clarifier
<br />TOP OUT
<br />Waste & Vent
<br />Water Pipinq
<br />Gas Pipinq
<br />Roof Drain
<br />Tub/Shower Test
<br />Rouqh Water Heater I /
<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
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<br />Rouah Plumbing
<br />Final Gas Test I
<br />Meter Release
<br />FINAL
<br />Note s, Remarks, Etc.
<br />PLUMBING-INSPECTOR RECORD
<br />ID/SIG. COMMENTS
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<br />OWNER llUILUEll l)ELCARATION
<br />I hereby arfirm under penalty of pe1j u1y 1hat I am e.'<ctnpl from the C'ontn1c1ors' Lic e nse Law for !he fol lowing n:n.si,n (Sec.7031.5 a
<br />B usiness m,d Professio n Code): J\ny C'ity or County which requires a pennit to constmct. alter. improve. de!n olish cw repair an y '
<br />structure . prior to its issu ance . .ilso requires lhe .i ppli cnnl for s uch permit 10 file a signed s tatement that he o r sh e is licensed p ursuant
<br />to t he provis ions o f the Contractor·s Licc11scd Law (Clmp1cr 9. Ccu nmcncing wit h Seel ion 7000 o f Division ., of the 13us iness and
<br />Profe~ions Code) or that he or she is exempt therefrom and the basis for lhe all eged e.xcmption. Any violation ofScclK'n 70~ 1.5 by any
<br />appl icant for a pe nnit subjects !he ap plicnnl to a Ci\'il pennlty of not more th an live hundred doll nrs ($500).
<br />_I. as owner of the property. or my employees with wag es as their sole compcns,ui on. will do th e work ;md t he sln u.:tun: is 1101
<br />intended or offered fo r s.1le (St-c. 7044 , Bus i11ess and Pro ft-ss itms Code: The Contractor's License Lmv docs 1101 nppl y IC1 nn owner of
<br />the propcr1y wl10 bu ilds or improves thcn:o n, and who docs sud1 work hi111 sclf or herself o r through his or her uwn emplC1yet..c.s.
<br />prov ided th at such im provements are not intendt..'CI or ofTere<.I for snle. If. however. 1he bu ilding or improve111en1 is sold wi1l1in one year
<br />of completion. the Owner Builder will have the burden of proving thm lie or she did not lx1ikl or improve th e propc.,1y for the puq')()sC of
<br />~,le).
<br />_I. rtsowner of the propct1 y. am exclusivel y contrncting with li censed conlr.ictors to conslruct the pmjc<.:t (Sec. i01M. Bus iness
<br />and Profession C'ode: The C'ontrnctor·s Lic ense Law <loes 1101 .ippl y to an owner of property who bu il ds <ir im prv,·cs the reon .
<br />.1nd who contracts fo r such prnjccts ,vith a Contrnctor(s) licensed pu rsuant to 1hc Contrnctor·s License Lmv).
<br />_I am exempt under Section. ________ . 0 . & P.C for this renson.
<br />0:1t,c: __________ Owncr:~========-==c-------------
<br />lVOllKF.l!S ' CO~ll'ENSATION
<br />D ECLARATION
<br />I hereby rtffinn under penn llyof pcijuryone of th e fo llowing declarat ions:
<br />_I ha ve nnd will ma in trtin a Cc11i ficntc o f Consent to Self-Insure for wc.,rkcrs ' co mpensatio n. ns provided for by Section J 700 of t he
<br />La bor Code. for 1he pt."ffonn.mcc of th e \\'Ork for which the permit is issued.
<br />_I have rtnd wi ll mrtintai n workers· co1 111:,ensa ti on insu rnncc . .is required by Seclic.,n 3700 of the L;1bor C'udc. fur th e pcrfi1rmnnce of
<br />the work for whic h this pcnnit is issued. M y workers· compcns.i tio n insurm1ce cmTier and policy nu mber nre:
<br />Carrier: __________________________ _
<br />Policy Nu ,n bcr: _____________________ Cxpires: __________ _
<br />~I ce11ify th at in the performa nce of the work for which this permit is issuc<l. I slmll not employ any person in any rm111m.:r
<br />so as to become subject to the workers· eo mpcnsm ion laws o f Californ ia. and agree th at if I should bernm~ subjc..:1 to lhc
<br />workers' compensat io n provisions of Section 3700 oft he Labor lode. I shal l. fm1h\\'ith comply wit h tho se prnvis il111s ..
<br />WARN ING : Failu re to secure workers' compc1 tion Cllvcmgc is unlaw ful. and sha ll subject an t..-,nplClycr to 1..,fo1in al penalties and
<br />civ il fine s up to one hundred thousand c.lollar ($100.000)~dition to 1l1c cost of cornpcnsmion. dm1mg cs as pro\·idcd for the
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<br />UE(.l(e;\R A 1 ION
<br />I hereby affi1111 11n nSed under pro\ 1~Cha~ommencmg \) ilh Section 70( O~__::i 3
<br />of the Busmess 15e IS 111 full fo • and effect \ )~
<br />License Class / 1ccnsc N r ' _ ____,,,
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<br />NS UC'TION LENDING AGENCY
<br />I hel'eby affirm under pe,mlt yof pe1jury that there is a conshr-t.1 ction lending. ngency for 1he performance of the \\'Ork for wh id 1 lhis penni t is
<br />issued (Sec. 3097. Civ. C.).
<br />Lender's Nc1mc: _________________________ _
<br />Lend er's Address: _________________________ _
<br />A PPLI CANT UECLARA TION
<br />I hc.i ·eby affinn under pena lly of perjury om: o f the fo llowing <lccl.ir.itic.llls:
<br />Dem olit ion Permits-Asbestos Noti lic.tt ion Federal Regulations (Titl e '10. Pm16)
<br />_Required Letter of Notificatio n
<br />I ce11 ify 1at the federal regulat ions rcgording. nsbest0s removal are not npplicablc to this project.
<br />I cct v hnt I hrt\·e read this npplicatio n nnd state that th e abo ve info nnat io n is com::ct. I agrt..>e h) com ply \\'ith ri ll City and Co unty
<br />ordinanc m State Laws relati ng to buil ding const ru ction. and hereby authorize rcprese111:itin~s of thi s C'ily and Cou11 ty lo c.·ntcr upon the
<br />above m nt mncd prnpc ,ty fo , mspcct,..po~ • ,· / ,! !
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