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PLU MBI NG-I NS PE CT OR RECORD APPROVALS DATE ID/SIG. C OMMENTS OWN ER llUILUER UEI,CA RATION I hereby aninn under penal ty of perjury that I run exempt from the Contractors · License Law for the fo ll owing rcnson (Scc.703 1.! UNDER GROU ND A Business and r rofcssion (ode): An y City or County whi ch requires a perm it to rnnslnu.:t. alt er. improve. dcnm lish or repair any stnicture. prior to its issuance. also reqltires 1he appl icant ftir such permit 10 file a signed srntement th;n he or she is li ce n~ecl i;-ursuan1 Waste & Vent ') ,,./_// -JI/VJ~~ i to the provisions of the Contractor's Licensed Ln w (Chapter 9. C'ommcncing wi1h Section 7000 of Di\'ision 3 of 1he l3us incss and ' Water-Un der fl oor I Vf 'v/ffa 'N/1 '/ Professions Code) or that he or she is exempt therefrom and the bas is fo r the alleged exemption. Any viol.it ion ufScc1 io11 703 ~.5 by any applicanl for a pe1111it subjects th e appli ca nt to a civil penalty o f not more than fiv e hundred doll<ll'S ($500). G as-Underfl oor '-. l _I. as owner of1h e property. or my employees wi1h wages as their so le compensation. will clo 1he work :md the s1ructure is not Buildinq S ewer inlendcd or offered for sale (Sec. 7044. Dusincss and Professions C'ode: The Contr.1c1or·s License Law docs not npply \Cl an ow,1er of the propt.i1y who lx1ilds ur improves tht.-reou. and who does such wol'k himself or herself o.-through his or her (1wn employees .... A rea/St o rm Dra in provided that such improvemeuts are not int ended orolTerc<l fo r sale . IC however. the bu ilJi ng or improvcmclll is so ld wiL~,in 011e year of comple1ion. the Owner Builder will h.ivc the burden of prov ing tlmt he or she did not bu ild or i1nprove the pmp< • .,1y for the pu rpose of Inte rce pto r/ C larifier sale). _I. as owner o f the propeny. am exdusively contrncting with licensed contrnc1o rs 10 cons tru ct the project (Set'. 7044. Business and Profession Code: The Contractor·s License Law does not npply to an owner or property who builds 0r im pro,·e!. tllcrcon. TOP OUT and who contrn cls for such projects wi lh a Conlractor(s) licensed pursuant to the Contractor's License Law}. W aste & Vent _I am exemp t under Sect ion . 13. & P.C ror this renson . Wate r Pi pin g Date; Ow11<'r: WORKERS' C O ~IrENSATIO N Gas Pip inq DE~:LAllATION I hereby affirm under pcn.1\ty or perjury one or the fol lowing dt::clarn tions: Roof Drain _1 have and wi ll main rnin a Ce11i lirnte of Consent to Self-Insure fo r workt··rs· compensat ion. as provided for by Section .'700 or the Tu b/Showe r T est Labor Code. for the pcrfonmmce o f the work for wh ich 1l1e permit is issued. Ro uqh Water Heate r _I ha ve and wil l ma int ai n workers· compensation insu rance. as requ ired by Section 3700 o f the Labor Code. for the pcrfo1111ance of ::":~;;;;;r 7!i~;7-·:: ;;s~;;z;rco:v P, POOL/SPA Policy Number: r' ~ 7 ?) n ft/ 18 Expires ~/4/4 ~ P-t r ap/Drain Lin e _I certify thal in the performance of the wor k for which thi s permit is issued. I shall not emp loy any person in nny manner Main Dra in/P ool Pipinq so as 10 become subject 10 the workers' co mpensal ion laws ofCalifomia. and agree that if! should become subject to the \vorkcrs' compensation provisions of Sect ion 3700 of the Labor Code. I shall. fo11hwith comply with th ose p1'0\'isi ons .. Fill Line/Back Fl ow WARNI NG failure to secure wmkeis' compensa11on cnvciag~1,lawr111. and shall subJ«:I an emp loyc, 10 m111111,1I p1.11al11es and Pool Heate r/G as Li ne c,v,I r.nes up 10 o ne hundr<-d 1ho us,111tl tlo llai,l0.000). 111 atl 111011 lo(j cost o r compens,1 1011. damages as p oov ,dcd for the Scct1on 3076 of the Labor Code. mte1est and al\01 e s fees // ' !<: . A .l Uate: t!/!t / ....--/{, A p1ili n t: I vr v -~ · Miscellaneous r I LIO'NSElVf·QN'l llAC ron D ECI,ARAT ION G as Serv ice I here by arfirm under penalty o f perjury that I am li censed under prov isioi1 of Chnpter 9 (comm e11c ing with Scctio11 7000) o f Division 3 of the Dusiness and Proressions Co de. and my license is in fu ll force and effect . Wate r Serv ice ~ LiceiJSC .. N l1111be1·: ___!7'~2 Lawn Sprin kle r License Class: \ / / . Sanita ry Sewe r/Cap DateA,4iJL-/£_':f_ G Con tractor: ./ .IJ/JvT / 1/7 I /:" 0 _) Back Flow Device v-./ --- CONSTRUCTION LEN lllNG AGENCY I hereby affirm under penalty of pe1ju1y tl1m there is a co11struc1ion lemling agency for the performance of the work fo r whi ch this permit is issued (Sec. 3097. Civ. C.). Roug h Pl umbi ng Lcnclcr·s Name: Fi na l Gas Test Lender's Ad dr ess: Me t er Re lease I I A PPLICANT DEC LARATION FINAL \/4 'If 5. 7)82_ ~ I hereby aflinn under penalty of pc1jury one of the fo llowing <lcc larat ions: Demolition Permits-Asbestos Notification Federa l Regul at ions (Tit le 40. Pnrt6) Not es, R e m arks, Etc. I _Required Letter of Notifi cation _I cei1iry that 1hc federa l rcgula1ions regarding asbestos r<:mo\'al nre not applicable to lh is project. _I cc"ify Iha! 1 lmvc read this application an; le 1ha1 lhc above inrormali on is co11ect. I agree 10 comply wit h '1 11 City and County ordin ances and St.ite Laws relating to bui lding c t ruction. and hereby .iut\mrize reprt>Sen1mives of1his ('i1y .ind County lt' 1:ntl-r upon the above mcnlioned prope"y for insp7,purpos . · App licant or Agent S ignature: '.' _' {t· J __ ,_. ,-· \ • Uatc:--jlJdtl/ };:j "b rermitce name (print): J \ /;'-I(_ 1) \ J \ I .1-l /\ ( \ I ) ----·''- v -