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PLUMBING-INSPECTOR RECORD ' APPROVALS DATE ID/SIG. COMMENTS OWNEll 8 UILDEll l>ELCAllATION I hereby amnn under penalty or pcrju1 y thm I ru n exempt li·om the Co 111ractors· License Law for the following rc:,,;on {Scc.703 1.5 UNDER GROUND i I Business and Profession Code): Any C ily or County wh ic h rt.·qu ircs a permit to c(i11s\ruct . alter. imprcwc. dcmt1l ish o r repair-;:qiy -I I stnicture. prior to its issuance. also requires the applicant for such permit to file a signed statcmenl that he or she is licensed purst•'lnt Waste & Vent 5/1) j)-'j 111l/3Lf to the provisio ns of the Contrac tor·s Licensed Law (Chapter 9, Commcm.:ing \\'ith Section 7000 of Division 3 of the Bllsincss and c:::AJ I II f1 wtl/t.;lf Professions Code) or that he or s he is exempt therefrom and the basis for the a lleged exe mption. Any violntio n of Section 7031.5 by any Water-Under floor applicant for a permil subjecls the applicant to a civil penn11y of 1101 mo re thM five hundred do ll nrs ($500 ). Gas-Underfloor ~ I _I. as owner of the prope11y. or my employees with wnges ns the ir sole compensation. will llo the work and lhc strnt.:tun.: is not intende<l or offered for sale (Sec. 7044. Busint-ss ;md Pro fessions Co<le: Th e C'o ntrat.:tor·s License Law dues 1101 apply In a11 owner of Buildinq Sewer the prope11y who builds or improves thereon. and who docs such work himself or herself or lhrough his or her own e1n ployet..'S. Area/Storm Drain provided that such improvemenls are not in tended or offered for sale. If. howcv(..'t·. the building or improvement is w k\ wilhi n ()!IC year of completion. the Owne r 13uildcr will have the burden ofpmving. tlrn t he or she did not build or i mprO\'C the prope11y for !he p uq,osc of Interceptor/ Clarifier snle). _I. as owner of the prope11 y. am e.xc lus ively co111rac1ing with licensed contractors to cons1ruc1 1he project (Sec. 7044. 1311.siness and Pmfession Code: The Contrnclor's License Lnw does n ot apply to an owner o f property who bui lds or impro\'cs thncon. TOP OUT and who contracts for such projects with a Conlrn.ctor(s) licensed pursuant to the Contractor's License Law ). Waste & Vent _I am c.xcmpt under Section . 8. & P.C'. for this reason. Water Piping Date: Owner: W ORK ERS ' fOi\lPENSATION l>E!,;LAllATIO N Gas Piping I hereby amrm under penalty o f pe1jury one of the following dednrnt io ns: Roof Drain _I have and will maintain a Certificate o f ('onsent to Self-Insure for workers· co111pc11s:uio11. as provided for by Section :0700 o f the Tub/Shower Test JCode. for the perfonnance oft he work for which the pennil is issued . Rouqh Water Heater _I hnve nnd will mninu,in workt:rs' compensation insurance. as required by Sect ion 3700 of the Labo r C'od c. for the pe rforman ce of the work for which this permit is iss ued. My workers· co mpensntion insu rance cm,·ier rmd policy number a re; . §,hJ.-e.-'F vt l'Jd C'm,·ier: POOL/SPA rolicy Number: . ~ 11, {o fl,, E xpires: . I I I J?>,JJ~ P-trap/Drain Line _1 certify that in the performance of the work for which th is permit is issued. 1 sha ll not employ an y person in any manner Main Drain/Pool Pioinq so ns to become suqject to the workers' co111pens ation ln ws o fCalifomin. and agree that if ! shou ld become subject l ll the workers' compensnt ion provisions of Sectio n 3700 o f the Labor Code. I shal l. fmthwith comply with those pro visions .. Fill Line/Back Flow WARNING: Failure 10 secure workers' compe nsation C0\'erng.c is unlawfu l. and shall subject an employer to c1iminal penalties a nd Pool Heater/Gas Line ci vil fines up to one hun dred thousand dollars ($100.U00J. in adllitio n to the cost of com pensnt ion. damages as pro\'ided ror the Section 3076 of the Labor Code. interest and attorney's fees. . \ 2 . (p ,I (o Awli<"ml: ~ JJi<i'f ~ L>ntc: Miscellaneous Ll!,;ENSED C rRJ 'T R DEC LARATION Gas Service I hereby affirm under penalty of pe1jury that I mn licensed under provision ofC'lmpter 9 (commencing wit h Sectiun iOOO t of D ivisi on J of the Business and Professions Code. and my license is in full force and erfect. Water Service q 5 I/ 2....2-.. Lawn Sprinkler License Class: ,, (? License Num ber: Sanitary Sewer/Cap Dace: . l '2' (o I l b Contractoc .,.. ~ =--- Back Flow Device ~:ONSTR!.!~:TION L ENDING AGENCY l I 11 I hereby affirm under pena lty o f perjury that 1here is n construction lending ngency for 1he perfonn.incc or the work for \\"hich 1his permit is issued (Sec. 3097. Civ. C.). Rough Plumbing r7f l-'b/14 WVl:-J.J Lender's Nmnc: Final Gas Test ( Lender's Address: Meter Release \ A l'l'LICANT IJECLAllATION FINAL 'f\\ \9. \M [1,t{ I hereby offinn under penalty o f perj ury o ne of the fol lowing. declarnt ions: Demolition Permi ts-Asbestos No1ificat io11 Federal Kcgulat ion s (Title 40. Pmt 6) Notes, Remarks, Etc. \ _Required LctterofNotilication I cc1ti fy that the rcdcral regulations regarding asbestos re moval are 1ml applicable 10 th is project -.I ~ei1ify tlrnt I have rend this applicnli on .ind st;it e thal the ;ibove infonn;itiun is co1;ect. t ngree to comply w ith all City nml Coun ty mdinanccs mid Slate Laws relating to building constn11.:1ion, nm\ hereby authorize representatives of this City and Coun1y \Cl enter upon the nbove mentioned propet1y for inspection purposes. Applicnnt or Agent Signnt urc: ~ ~~ l>a te: -JZ...,(,.l l r cn nitcc nn mc (prinl): ~ £.L--INQR... &+A/ ci:J 15dh ----