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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG. COMMENTS O WN ER IIUIL OER OELCAR ATION
<br />I hereby affirm under penalty of pe1jury tha t I am c ,,cmpt from the Contrnc1o rs' Licens e L.tw fo r the following rensn n (Sec, 7031.5 .
<br />UNDER GROUND l3us incss ,md Profession Code): Any C'ity or County wh ich requi res a pt11nit to const111ct. niter, im prove. dem olis h or repair :iny
<br />st n1 c1ure. prior to its issuance. also requ ires the applicant ro r such permit 10 lite a signed sta1eme111 tluu he or she is licensed pursu¥!1 Waste & Vent f'Nt:1 Per ,) K. 3.(. rM lob ~~ to the provisions of the Contractor's Licensed law (Ch.apter 9. Commenc ing with Section 7000 of Division J of the Blisiness a nd
<br />Water-Under floor Z/>, 11,. -Professions Code) or that he or she is exempt therefrom and the b.1sis for the al leged exernptio11. Any \'io lation of Section 703 1.5 by an y
<br />applicant for a permit subjecls the applicant to a civil pcn ahyofnot more than live hundred dollars ($500)
<br />Gas-Underfloor _I. a..:. owner oflhe pro perty. or my employees wi1 h w.iges as their sole compensat io n. will do the wor k nnd the st ructure is not
<br />Buildina Sewer intended or orTered for s..1le (Sec. 7044. Business and Professions Code: Tl1e Contrnc1nr·s Lic en se Law does not apply 10 nn owner of
<br />the prop!,.,i'ty who builds or improves thereon. ;md who does such work h imself o r herse lf or through his or her mvn emr loyces.
<br />Area/Storm Drain provided that such improvemenls are 110 1 intended or ofTt.-,·ed for s.1lc. If. however. the building o r impro,,cmcnt is sold w ithin cme year
<br />of complctKln. the Owner Builder will ha\'e the burden of proving that he or she did not bu ild or improve 1hc propc,1y for 1he purpose o f
<br />Interceptor/ Clarifier s.1le).
<br />_I. :'IS owner oflhe property. am exclusively cor11rt1cling with licensed cont,~ctms to cons1ruc1 t he prnjc1.:1 (Sec. 7044 . B11sim.-ss
<br />and Profession Code: The C'ontrnc to r·s License Law does nC'lt apply to an owner of property who builds or impm\·es the reon.
<br />TOP OUT and who contracts for such projects w ith a C'ontral·tor(s) licensed pursuant to the Con1rnc1or·s License Law).
<br />Waste & Vent _I amemu2unclerSection . . 0. & P.C-. forth/':~
<br />Water Pipinq Dale /& ,?j_ J O {O,,ner J<. ~ /~,
<br />' ,{v()lu<Ens• CO~JP , A"J )N
<br />IJEC LARATIQN ~ Gas Pipinq I hereby affirm un der pennltyof perjury one of the fo llowing dcdnrntions:
<br />Roof Drain . _1 have and will mai ntain a Ce11 ilicatc ofConscnl to Self.Insure for workers· compensat ion. as provided for by Sec1inn J700 of the
<br />Tub/Shower Test rlt-;;( 17 ~V//_uf/1) Labor Code. for the perfonnance o f t he work for which 1hc permit is issued.
<br />Rouah Water Heater I _I have nnd will ma int.i in workers' compensation insurance. ns required by Section 3700 uf1he Labor Code. for 1he perfonnance of
<br />the work for which this pennit is issued. My w ork<..i·s · compcnsillion insurance ca1Tic r and IX'llicy num ber arc:
<br />Ca1rier:
<br />POOL/SPA Poli cy Number: Expires:
<br />P-trao/Drain Line _I cc11ify thnt in the performam.:e of the wo1·k for which tl1is permit is issued. I s hall not employ any person in any 111:umer
<br />Main Drain/Pool Pipinq so as to become subject lo the worh·rs' compcnsmion laws ofC'alifo rni n. and c,gree Ihm if I slmuld become subject 10 the
<br />wor kers' compensation provis ions o r Section ,l,700 of the Lnbor C0<.lc , I slm ll. fcH1hw ith c,,mply w ith thQSC provisiu ns ..
<br />Fill Line/Back Flow
<br />WARNING: l'ailurc to secure w orkers' comre11sa1ion con:rngc is un la wful. mid s hall subject an employer 10 criminn l pena lties and Pool H eater/Gas Line civil r.n,·s up to one hund,·ed thousand dollars ($100.000). in addit ion t,'.-":u'°mpcnsation. damages as prn,·idcd for the
<br />Sectio~,c L.1bor Code. interest and att orney·, fees. . I
<br />• ;J?) ? hi ~ / -~ -Dafe: , r) Applirnnl: t ,,,,.~ r .,,, -/ v 1 Miscellaneous { L"':Jl N°s lm CONTln'"TOI! ~
<br />llJ,:,C:LAl!ATION Gas Service I hereby affirm under penalty of perjury tlrnt I ain lict:nsed under pm vision of C h np1er 9 (commencing with Section 7000) of IJivision 3
<br />Water Service of 1hc Busint!Ss and Professions Code. and my li cense is iu full force and effect.
<br />Lawn Sprinkler License Class: License Number:
<br />Sanitary Sewer/Cao Uafe: Contractor:
<br />Back Flow Device
<br />!:;ONSTR!,!CTION LENIJIN!, AGENCY
<br />I hereby affirm under penally of pe1:jury that 1here is a co11struc.:1ion lcndii1g ,1gency for the perfonn;mce of the work for w hich 1his pennil is
<br />issued (Sec. 3097. Civ. C.).
<br />Rouah Plumbing f l n 1t7 / ~~(f},, Lender's Name :
<br />Final Gas Test -·, ~
<br />Lenclcr·s Address:
<br />Meter Release I A PPLI CA NT DECLARATION
<br />FINAL /''LI ~;7r:; s '/ r-~ ~,;.-~ ,, I herebyaffinn under penally ofpe1jury one of the following dec larations:
<br />, / Demolition Permits~/\sbcstos Notification Federal Regulations (Title 40. Pa116)
<br />Notes, Remarks, Etc. _Required Le11er ofNot ificatio n
<br />j-2.-17; UNIJ~~(Z, CJN/.X
<br />_I certify that lhe federal regulations regarding asbestos removal are not .ipplicnblc to this proj ect.
<br />_I ct.i1ify 1ha1 I have rc;id this .ipplicaiion and slate t hat the abo\'c infonn .ttion is coffee\. I ilgree to comply w ith a ll Cily and Co unty
<br />ordinances and State Laws relating 10 build ing~~ hereby authorize representatives of this City and Count y to enter u po~
<br />a bove mentioned prope11y for ins p~n pw·poses. ,-/4 . ,
<br />Ap1>lican1 or Agent s;gnalure: ~ £4 "'7~ D:lle:R./d 2.._ 7 ul
<br />Pcrmilce name (print): DI r2--,~A_J
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