|
APPROVALS DATE
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor
<br />Gas-Underfloor
<br />Buildina Sewer
<br />Area/Storm Drain
<br />lnterceotor/ Clarifier
<br />TOP OUT
<br />Waste & Vent
<br />Water Pioina
<br />Gas Pioina
<br />Roof Drain
<br />Tub/Shower Test
<br />Rouah Water Heater
<br />ID/SIG.
<br />I {I V
<br />PLUMBING-INSPECTOR RECORD
<br />COMMENTS OW NER BUILD ER D llLCAllATION
<br />l hereby affirm un der penalty of pe1j ury th.it I run exempt from the CCln lrit clors· License Law fo r the fol lowing rcasCln (Scc.703 1.5
<br />Business and Profession Code): Any City or County wh ic h requi res a pcnnit to construct. alter. im prove. dc111olish or repair any
<br />stru cture, prior 10 its issu an ce. also req uires l hc .ippli ca rll fo r such pem1i1 to li le a s igned statement that he or she is li censed pu rsuant
<br />to the provis ions of the C'ontrnctor's Licensed Lnw (Chapter 9. Commencing with Seel ion 7000 o f Divis io n ~ of th!! Business a nd
<br />Professions CodcJ o r that he or she is exempt therefrom and the basis for the alleged C:<em pl i on. Any violation of Section 703 1.S by any
<br />applicant fo r a permit subj t.--cts the applkanl to a civil penalty of not more than five hundred doll ars ($500).
<br />_I, a.<; own er of the property. or my e mployees with wngcs ns IIH.:ir sole compensat ion. will do the work and the strucrnrc is not
<br />intended or oITercd for sale (Scc.7044. Business an d Professions Code: The Contrnctor·s License Law d or .. "'S 1101 npply tu ;in ('lwner of
<br />the pmpt,ty who builds or improves thereon, and who docs such wo rk h imself or herse lf or 1hrough his or her own c111plo)CCS.
<br />provided l hnt such improvemenls .u-e not intended or offered for sn lc , If. however. the bu ildi ng or impro\·cment is sold \\'ith i11 011e year
<br />of comple1 ion. the Owner Bui lder will liavc the bur d<;,-n of proving chat he or she d id no! build or i mprove the propcit y for the pu rpo se of
<br />sale).
<br />_I. as owner o f the propet1y, am exclusively contracting with licensed con1rac1oi-s to conslruct t h e p roject (Sec . 7044 . B usiness
<br />and Pmfcssion Code: The Con1 ractor·s License Law does not a pply to an owner ofpropr11y who bui lds o r improves I hereo n .
<br />and who c onlrncts for such projects w ith a Contrncl or(s) licensed pursuruH lo the Conlr:ic1o r·s License Law).
<br />_I run exempt under Section, ________ • 8. & r .C. fo r this reason
<br />O ,ue: __________ Own er: _______________________ _
<br />WORKERS' CO~ll'E NSAT IO N
<br />DECLARATION
<br />I hereby affirm under penc1hy ofpt.'"ljury one of the fo llowing declarat ions:
<br />_I have and will maintnin a Ce11ificate of C o n sent to Self-Insure for workers· com pensat ion. as provided for by Scr1 ion .HOO o f the
<br />Labor Code. for t he perfonnance oft he work for which the permit is issued.
<br />_kftrnve and will maintain workers' compensation insurance, as required by Sectio n 3700 oft he L.ibo r Code . for the pcr fonnance of
<br />the work for which this pcnnit is issued. My workers· compcnsmion ins urance cnn·icr .ind policy number nre:
<br />1-----------------i-----+-----1-------------'-',jVcanicr:l:k e A WI e,, C.Ct .,.__ \ V\ <;, V -i-c. "'' e ( o '"""-?'°'" • /
<br />POOL/SPA , Po licyNum ber KW C CLf &<go 7 ?::>31 Exp ires 4/.../11 1--__;_.....;_;_;_;_..:.,_ _________ I--------I-------II------------------A I
<br />P-trao/Drain Line _I ce1tify that in t he performance oft he work for which this permit is issued. ( shall not employ ,my per son in nn y manner
<br />so ns to become subject to the workers' co mpens.uio n laws o f Cali fornia. and agree that if I should become subject to the Main Ora in/Poo I Pi oina workers' compensation provis io ns o f Section 3700 of lhc LnOOr Code. I shall , fo 11h wi1h co1nply with those provis iOl lS ..
<br />Fill Line/Back Flow
<br />Pool Hea t e r/Gas Line
<br />W A R N I NG : Failu re to secure workers' compe nsation ccwern.gc is tmla\\'ful. and s hall subject an cmpk1ycr In c.,imina l fX.'.n.11\ies and
<br />ci\1il fines up to one hundred thousand dollars ($100.0 00). in add ition to the y 1 of cc11npensation. damnges ns p nwided for the
<br />Section 3076 of the Labor C'odc. inter est and attomey's fees. ,..-?' [;,' I;)../ / . -;::,::,,,-•/-y
<br />t--------------------1---------if--------f------------------,I\. Dal e: I •t / f lo Ap1>li cant:. ____ ,..-:.,c:.·/ __ /~"--.::.·•_c_. __________ _
<br />Miscellaneous , "· urnNs ED,e:6NTJMt:rnR
<br />t--------------------1---------if--------f------------------l DEtLAIM JO N Gas Service I h ere by affirm under penally of perjury that I nm li censed under provision of Chapter 9 (conuncncing with Secti on 7 000) of D ivis ion 3
<br />o f the Business and Professions Code. and my lic ense is in fu ll fo rce and effect.
<br />Water Service c.. 1-_ r ~ 'QC. _,:-;-cl, Law n Sorin kier cense Class.:_ ----="---~~..c..._,1/4,=_ _____ Licensc Number: _ _..;:...,;;.....1e( _ _1_.,_-=.....;;a;_....:. ____ _
<br />Sanitary Sewer/Cao / r\ IJnlc:
<br />1
<br />)_,/ \ '\ { \ \o Conlrnclo r .: ___ ·,,_~:,,_,·;,:_J-_,_7c_.'.;...-~---------l-=-=:.:::..:.....t.-=-=:....:..:...::..:..:....:=..=.c:.... ___ -l-------l-------1------------L-11 \ /_/--i
<br />Back Flow Device coNsmun10; ;EN i~
<br />1
<br />Ac ENcv
<br />Rouah Plumbina
<br />Final Gas Test
<br />Meter Release
<br />FINAL
<br />Notes, R e m a rk s, Etc.
<br />I hereby a ffir m under penalty of petjury tlmt there is n cons1mctio11 lcndi11g .igency for the pcrfonuancc c,f the W(l r k fi.ir which this permit is
<br />issued (Sec. 3097. Civ. C.).
<br />Lender's Nmne: _________________________ _
<br />Lender's Address: _________________________ _
<br />A l'l'LJC A NT DEC LARATION
<br />I ht..'"rcby affin n under penalty o f perjury one of t he following declarations:
<br />Demolit ion Pcnnits-Asbestos Notificaiion Federal Regulation s (Tit le 40, P:ut6)
<br />_Requ ired Leiter of No tificatio n
<br />C, ·ys _, 7 -I A-14 J._, d. 1 A I I =-1..S . €) Cl~ ,t")+1,) £,.... { ..f<; t; n..l t I,) A-rev<-JL,f_.t:-_I ce,tify lhal 1he federal reg ul at ions regardi ng asbestos rcmov•I •re 11 01 app licable to t his project.
<br />/,)..,,__r-,A_ ,Ao ..t J...J,,,,-· Lll-v /.:.~~£.... K ~ /_ -• J o' / '1.h J J.e <'1!2.../-,; M -' ce11ifythat I hnverend lh isnpplication and stnlclhal thc.iOOvc infonm1t io n is con·ect. I a grt"ClO comply with .ill C ity a nd County
<br />~ -\..,/" mdmanccs and State Laws relating to bu1khng COll'>lrnctron. nndz 1ere y ;m lm1ize reprcsentall\cs of1l11s C it y .ind Cou nty 10 Clllt:r upon the
<br />1--------------------1-------+------J-------------------~~ above 111e1111ont:d p1operty for inspection pm poses I t
<br />\-....,_ • . ,-~ --· . l Z //,/ / {
<br />1--------------------1-------+------t-----------------/--J(/A pplicanl or Agen t Sig 11 alure: J_../ V/ ~-~ ~. n Dal e ~
<br />'ermilee m1111e (p rinl): ,.;•••''/..,. ~o. \)tr\ es ~c r &V\.e~
<br />?
|