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PLUMBING-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG. COMMENTS
<br />UNDER GROUND
<br />Waste & Vent
<br />Water-Under floor '1,,v ..
<br />OWNER llUI LIJER IJELCARATION
<br />I hereby affirm under penalty of perjury 1luu I am exempt from !he Contractors· License Lnw for the fo llowing reason (Sec.7031.5
<br />Business and Profession Code): Any City or Coumy which requires a pt11nit lo construct. al ter, improve. dem olish or repa ir any
<br />stmcture. prior 10 it s issuance. also requ ires the t1pp!icant for such permit to lilc a signed statement that he or she is fo.:ensed ' pursu ant
<br />to the provisions of the Contrnctor's Li ce nsed Law (Chapter 9. Commencing with Section 70 00 of Divis ion .1, of the Busi ness and
<br />Professions Code) or that he or she is exempt therefrom and the bas is for th e alleged c.xemp1ion. Any violat ion o f Sectio n 7031.5 by any
<br />applicant for a pcnnit subjec ts the applicant lo il ci vil penalty of not more than fi ve hundred dolla rs ($500).
<br />Ga s-Underfloor _, Ov"-"I \ / ~ )-1. as owner of the propcny. or my employees with wnges as their sole co mpens11tion. wi ll do the wo rk a nd lhc SlntC1lffC is oot
<br />t--------------------1-------+------t--------+ .i.-.,-,a"l'--Fr--....-'J,/7 yb-'~r:,~'1rl'l,rJ int<,·ndt-d or orTered for sale (Sec. 7044. Busi ness rind Professions Code: The C'ontrnctor·s License Law docs not apply to an O\rncr or Buildina Sewer O .l ~JJJ' \·A~) '1:7 C O'f / the proJX.C>ftY who bui lds or improves thereon. am! who does such wo rk himself or herself or tl1rot1gh his or her own employees.
<br />t-----""--=---'---=-----------1-------+------t-un--, 0.---.11,.l ,_le,~ 1/;.:.._ .-1id.,4'"'--:vl}'--"~, '\-t,;rl,'-->-£..-J provided that such improvements are not int~1ded or offered for sale. If. however. th e bui lding or im provement is sold ,,·it hin one year Area/Storm Ora in _.... ff.JI -\0 of completion. tl1c Owner Builder will have the burdt."11 of proving th.it he or she did not build or iin prove the pro1>e11y for the pltrpose of t----"--=-=--=-..:..:...:....:..:...:.-=...:....:=...:....--------1-------+-----'-l-------'-------~-,J.".:.._------I sr1lc).
<br />lnterceotor/ Clarifier
<br />TOP OUT
<br />Waste & Vent
<br />Water Pioina
<br />Ga s Pipinq
<br />Roof Drain
<br />Tub/Shower Test
<br />Rouah Water Heater
<br />POOL/SPA
<br />P-trao/Drain Line
<br />Main Drain/Pool Pipinq
<br />Fill Line/Back Flow
<br />Pool Heater/Ga s Line
<br />Miscellaneous
<br />Gas Service
<br />Water Service
<br />La w n Sprinkler
<br />Sanitarv Sewer/Cao
<br />Back Flow Device
<br />Rough Plumbing
<br />Final Gas Test
<br />Meter Release
<br />FINAL
<br />Notes, Remarks , Etc.
<br />I
<br />I
<br />I,
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<br />_I. as owne r of the property. run exclu sively contrncting with licensed contrn ctors 10 construct the projcc.:t (St.'t'. 7044. I3us im.-ss
<br />and Proft:SSion Code: The Contractor's Lice nse Law does 1101 apply to an ow11cr o f property who bu ilds m im prcwcs th ereon.
<br />and who contracts for such projects wi1h a Co ntractoi1s) licensed pursuant to 1he Conlractor's License L1w).
<br />_I am exempt under Section, ________ . 8 . & P.C. for this reaso n.
<br />Date.; ___________ Owner ; _______________________ _
<br />WORKERS' CO~I PENSAT ION
<br />l>lcC L A RA TIQN
<br />l hereby nffirm un der penalty of pc,jury one of th e fo llowing declarations:
<br />_I have and will main tain a Certificate or Consent to Self-Insure for wof'kcrs· com1>e11s.1tio n. as pmvidcd fo r by Section 3700 o f the
<br />Labor Code, for the pcrfon na nce oflhc work for wh ich the pennit is issued.
<br />_I have and will m.tint~i}i.'';orkers· compensntion insurn ncc. a~ required bY. Sect io n 3700 of the Labor Code. ror th e perfonnance of
<br />the wo2"ht this p~i ~~ iss11cd~My workJ\s _co~npcnsa~on insur"t~ carrier and poi!,numbcr ~
<br />CmTicr .Fl r 6 . -,',M,+tJl/l~,,,,-;;f-f cv'l f-l.A1
<br />\"' Policy Number:. _____________________ Exp ircs : __________ _
<br />_I certify th al in the performa nce of the work for wh ich thi s permit is issued . I shn ll not employ ,my pe rson in any ma nner
<br />so as to become subjccl lo the workcl's' co mpcnsnt ion laws of Ca lifornia. and .igree that if I should become subjecl to the
<br />wo rkers' compensati on provisions ofSeclion .3700 of the Lnbor Code. t shall. forthwi th compl y with those provisions ..
<br />WARN ING: Fai lure to secure workers' compeei~1s;11ion ·,n••.~:..ge Is . nlawfol. and shall subject an crnpl{'lycr to ai minill pcnalt~ and
<br />civil fines up to one hundred tho usand dollars {$1 0 .000 ). in a z1tion to lhe ost of co mpensa tio n. da mages as pro\'ided for the
<br />Sec1ion 3076 of the L~Cod~i,01 est and allorn s fees .
<br />I ...-:)_ ,~, / -. I""-..
<br />Dntc:c:7~ _,,_ Applicant:;_~P~--1-~'~,.·~--------------
<br />LICENSEI> CONTRACT OR
<br />DECLARATI ON
<br />I hereby affirm under penalt y of perjur y that I am licensed under provision o rrh~pter 9 (commencing, wilh Sec tion 7000 ) of Division 3
<br />of the Busm~nfessions Code, and my license i~~•nd effect._. ti~ u
<br />Li ccnseC'loss~ A /L_Li censcJ:~ 6 -:,_
<br />Date; ( ,:;;;-I L;,,-l 6 Conlrncto1 .. _ --= -_·w~_,:z_:.._==·---------------
<br />CONSTRUCTI ON LENUING AGENCY
<br />I he reby amrm under penalty of pe1j ury th.it there is a c<mstmction lendi ng agenc y for the pcr fonnancc o r1 hc work for which th is pcnnil is
<br />issued (Sec. 3097, C iv. C.).
<br />Lend er's Name: _________________________ _
<br />Lendcr·s Address: _________________________ _
<br />APPLICANT DlcCLARATI QN
<br />I hereby aflinn under penally of perjury one or the fo llowing declarm ions:
<br />Demolition Permits-Asbestos Notifica tion Federal Reg ulat ions (Title 40 . Pa116)
<br />_Required Leller of Notificatio n
<br />_I cer1 ify that~he federal regL ons re gardi ng a l:x:stos removal are no t app lic.ible 10 th is project.
<br />_I ct.,1ify that I have re his application and st;II tha9 the i1 ', infonnation is co11"cct. I agree lo comply with all C'ily a nd Cou nty
<br />ordinan ces and Stale L 1s relat in~ to build ing con. 11ctio11., •reby aut hor ize reprcscnl.llivt.-s of th is Ci ty and Co17?,n1y t enter uihe
<br />above mentioned pro e11y for inspection purpos . '2' ' V
<br />I · ~o
<br />Applica111orAgenl ~1gm11u1 . // D:t le:...,,-~------
<br />Pe rmilcename(print); , '\r,t l?.....f'A . S'((a...b
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