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APPROVALS DATE ID/SIG. UNDER GROUND Waste & Vent Water-Under floor Gas-Underfloor Buildinq Sewer Area/Storm Drain Interceptor/ Clarifier TOP OUT Waste & Vent Water Piping ;>.,. Gas Piping '71 F(./tc~J..J Roof Drain /.J~ VIV Tub/Shower Test Rouqh Water Heater POOL/SPA P-trap/Drain Line Main Drain/Pool Pipinq Fill Line/Back Flow Pool Heater/Gas Line Miscellaneous Gas Service Water Service Lawn Sprinkler Sanitary Sewer/Cap Back Flow Device Rough Plumbing Final Gas Test Meter Release FINAL Notes, Remarks, Etc. V PLUMBING-INSPECTOR RECORD COMMENTS OWNER BUILDER D EL CARATION I hereby affirm under pena lty of pe1jury that I run e.xempt from the CC1n tra c1ors· License Law for the following rcasm1 (Scc.7031.5 Business nnd Profession Code): Any City or Coun ty which requi res a pmnit to co11s1 n.1 ct. .i hcr. improve. dcmq l ish or repair• any structure. prior to its issuance. also requires the ap plicmu fo r such pennit to {i]c a signed stalcmcnt 11ml he or she is licensed pursuant to the provisio ns of the Contractor·s Licensed Lnw (C'lmp ter 9. Commencing wit h Section 7000 of Division 3 or t he Business and Professions Code) or t lmt he or she is exempt therefrom and t he basis for the a lleged exemption. Any vio lat ilrn ()fScl't ion 7031 .5 by any ripplicnnt for a permit subjects the appl icant 10 a civi l pen.illy of not 111o re than fivt: humlrcd dollnrs ($500). _I. as owner oft he prope1ty. o r my employees with wages ns their sole con1pensation. will do the \\'Clrk and lhc s1111cnu·e is not intended or offered for sale (Sec. 7044. Business and Pro fe.~s ions Code: The Contractor's License Law docs not npply lo an owner of the property who bui lds or improves thereon. aml who does such wo rk himself or herself or 1hrough his or her own employees. provided that such improvemen1s are not intended or offered for sale. If. howcvc.>r, the buil ding or improvement is sold withi11 one year of completion, !he Owner Builder will have the burden of prnving that he or she did not build or improve the propes1y fur the puq)Ose of sale). _I. as own er of the pro peity. am exclus ively contrn ct ing with li censed contractrn"S to construct tl1 e project (Sec. 70--l4. Business and Pro fl'Ssion Code: The Conlracwr's License Law does not apply to an owner o f prope11y who b\lilds or impnwcs tht.:n.:on. and who conimcts ror such projects with7ntract or(s) licensed purs uant to t he Controcto(s License Law). Dnl~17~•~z~1.\rt1Cr: . D. & l'.C . for this reason. (--,-v-o _R_K~E~ll~S~' ~c-o~~~ll~'E~,N-S~A~.~rl-O_N ____________ _ lllcC LARATION I hereby affirm under penalty of P;!i 1ry one o f t he fol lowing declara1ions: _I have and will maintain a Certi ricatc of Consenl In Self.Insure for workers· compcnsn1ion. as provided fo r by Sec1ion 3700 oflhe Labor Code. for the pcrfonnance o f t he work for wh ic h the pcnnit is issued. _I have ;md will maintain workers· compensntion in surn.nce. as required by Section 3700 of1hc L.ibo r Code. fo r the performance of the work fo r which this pcnnit is issued. M y workers· compensation insu ran ce cnll'ier and policy number are: Ca1Ticr : __________________________ _ Pol icy Numbcr: _____________________ Expires: __________ _ _1 cc11ify 1hat in th e performance o f the work for which this permit is issued, I shrill not employ any person in any mmmcr so as to become su bjcc1 to the wo rkers' compcns.ition lnw s of('nliforni a. and agree t hat if I should become subject to the workers' compensm ion provisions of Sect ion 3700 of the Labor Code. I sh.ill. fo1thwith comply wi1h those provisions .. WARNING : Failure to secure workers' compensation coverage is unl aw ful. and sha ll subjt.:ct an c.inpluyt.:r to 1..,·i111in.il pena lties an d CIVI i fines u p to om: h u nd1 ed tho usand dollnrs ($100.000). m add1t10 11 t o th e cost of compensat io n. dmnng es as p1(WRlc<l fo r the ::ct~~" ,o;z;•; 7;;,tc,~ and :li:::::s f~/J ,/J ///f - l f ,..r·,=m coN'rl'tAc,'<hR / (,,,/ 11/' '/ / / ' DECLAU.A'llON..... {;/ I I hereby afrirm under penall y of pc1jury1 ha t I mn u.: under provisio n of Chapter 9 {commenci ng with Scctic,n 7000 ) of Division 3 of the Bus in t::ss and Proft..-ssio ns Code. and my license is in ful l fo rce and eff~I. Li cens e Class· / Li cense Nu1nbc r: _______________ _ Dntc:--2-P¥ll.i Cunlrnctor: ___________ _ / tG ONSTRUCTION LENDING AGENCY I hereby afrirm und er penalty o f perjury that th ere nstmction lending agency for th e perfonnance of th e work fo r which this permit is issued (Sec. 3097. Civ. C.). Lender's Name: _________________________ _ Lende r·s Address: _________________________ _ A l'l'LICANT DECL A RA T ION I hereby nffinn un der penalty of perjury one of 1he fo llowing declnrntions: Demolit ion Permit s~Asbestos No1ifica1ion Federn l Regul at ions {Title 40. Pmt6) _Required Lett er of Notification _I cci1ify ti I the federal rcgulatic,ns reg.trding .isbt.."SIOS rcmovnl arc no! appl icable to 1his project _I co ·fy nl I have re.id this appl ic ation ,md sl.t\C thnt th e above infornmtion is con·ecl. I agree In comply with all Ci1y nnd County ordin ance 1d State Laws relating to buil ding construct ion. and he reby aut horize representati ves of this City ::md Count y to i:ntcr upon the abo\'c me io cd prope11y fo r inspecti~ ~ ~ __... ~ ./4 Applic:~ntorAgc11t ,g11At 11 rc: ~/ X Y ~~ Datc:2~} /I/ .,....L,. -, , I 7-L 1,er,11itce e ri11t): -~ ~---------------- 7 .•