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PLUMBING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BI'ILDER DELCARATION <br />I hcrcby allirm undcr pcnally of perjury lhal I m cxcnpt frcm lhc Contnclos' Liceorc lrw for thc following rc&sn (Ss.7031.5 <br />Busincss 8nd Pmftssion Code): Any Cily o County which rcquircs 8 pcrmil to construct. sltei imprcvc, dcmlish or rcJnir any <br />struclurc, Jrk r to ils issuancc. ds rcquircs thc applkml for swh pcmit to filc 8 signcd sl8lcrcnt &sr he or CE is liccnsd puset <br />to thc prcvisioos of the C-nhctor's Lbensd tiw (Chaptcr 9. Commrcing with Sction 7fiD of Division 3 of thc Busircss ild <br />PrcfcssionsCode)sthdheorsheiscxetrptthmftomedthebqsisforthcallegcdexcqrtion. AnyviolathnofSelionT03l,5by8ny <br />rpplicant for a pcmit subj(ts thc spplicsnt to a civil pcmlty of not mre thm five hundrcd dollars ($500). <br />-1. <br />as owncr of thc pmf,erty. or my cmployecs with wages ss their sole comlrcnsalion. willdo thc work and thc stnrture ls nol <br />intcndcd or offercd for salc (Scr.7044. Busincss and Profcssions Code: Thc Contractor's License Law docs not apply to an owner of <br />the propcrty who builds or improves thercon. and who docs such work himsclf or herself or through his or her own cmployecs. <br />providcd that such improrrenrnts arc not inlendcd oroffered for salc. If. howcver. thc huilding or inqrroverEnt is soH within one )rcBr <br />of complction. the Owner Buildcr will have thc burden of poving that lrc or she did not buiH or imprnrrc ttrc fnopcrty for the purposc of <br />salc). <br />-1. <br />asowtrcrof the propcrly. amcxclusivelycontracting with liccnsctlconlractors to conslruct thc projcct (Scc. 7(X4. Business <br />and l'}rofcssion C]odc: Thc Contraclor's Liccnse Law docs not apply to an owncr of property who huilds or inrproves thercon. <br />and who conlrucls tbr such projc'cls with a Contractor(s) liccnscd pursuant t<l thc Contractor's Liccnsc Law). <br />-lamcxclnptundcr.Sccti<rn-.B.&P.C.tilrlhisrcason.I)nle:0wner:_ <br />WORKF.RW <br />DECLARAT]ON <br />I hcrcby alTirm undcr ;rcnalty of pcrjury onc of the following dcclarations: <br />-l <br />have and will rnaintain a Certificatc of Consent to Sclf-lnsure for workers' compensation. as povided for by Section 3700 of the <br />L-abor Codc. for the grcrfornunce of thc work for which thc permit is issued. <br />-l <br />havc and will maintain workcrs'compensation insurance. as requircd by Scction 3700 of the Labor Code. for the performancc of <br />the work for which this pcrmit is issued. My workers' compensation insurancc carricr and policy number arc: <br />Policv Numbcr: Exnircs:, <br />-l <br />ccrtily that in the prfbrnrancc of the work lbr which this pcrmit is issucd. I shall not c:rrploy any pcrson in any m&nner <br />so aslobccomcsubjccttothcworkers'contpcnsationlawsofCalifornia.andagreclhatiflshouldbcconrcsubjccttolhc <br />workcrs' comJrcnsation provisions of Scction 3700of thc L;rtnr Ccxle. I shall. forthwith comply with thosc provisions.. <br />WARNING: Failure lo sccurc workers' compensation coveragc is unlawful. and shall subject an employer to criminal penalties and <br />civil tines up to onc hundrcd thousand dollars ($100.fint. in addition to thc cost of compcnsation. damagcs as provided for thc <br />Section 3076 of thc labor Code. intcrest and attorrrcy's fees. <br />Applicant: <br />LICENSED CON'I'RAC'I'(TR <br />DECLARATION <br />I hcrchy allirrn undcr pcnulty ol'pcrjury that I anr liccnscd undcr provision of Chaptcr 9lcorrrnrcncing with .Scclion 7Un) of Division .1 <br />o[ the Business and Prol'cssions Codc. ancl nry liccnsc is in full frrrce und cft'ect. <br />License Class: License Number: <br />( 'ortl rlrt'lor <br />W <br />I hcrcby affirm under Fnalty of pcrjury thrt thre is a constructhn lcnding agcmy for thc perforw ofthc work for whhh this pcrmit k <br />issucd (Ss. 3097, Civ. C.). <br />Lcndcr's Nanrc: <br />lrndcr's Addrcss: <br />A PPLICANT IIECLARATION <br />I hcr$y allirnt undcr pcnalty of pcrjury onc of thc folkrwing declarat ions: <br />Dcntolition Pcrntits-Asbcslos Notification Fedcral Rcgulations (Titlc 40. Part(r) <br />-Rcquircd <br />l-ctlcr of Notification <br />-l <br />ccrlily lhill lhc l'cdcr{l rcgul.lkrns rcgudilg astrcstos rcmoval urc nol appliclblc to lhis pmFct. <br />-l <br />ccrtily thilt I hilvc rcild this npplhdlion und strlc lhilt lhc akrrc inlilrnutior is corccl. I agre to comply with trll City and County <br />ordinancc$ ond Statc liws rclaling to huilding constructiur. atrd hcrcby tulhoriTc ]cprcsntilti!c$ of Ihis City ond County lo cnlcr uF)n thc <br />ilJ$!t mllioncd propcny for irtspcclion purF)scs. <br />Applicant or Agent I ):rIt. <br />l)t'rrtrilee n:rnre ( ;lrilrl ) : <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf Ioor <br />Building Sewer <br />ArealStorm Drain <br />I nterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rouqh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />Main Drain/Pool Pipinq <br />Fill Line/Back FIow <br />Pool Heaterlcas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary SewerlCao <br />Back Flow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release I I <br />FINAL I lutLil Dhrys 1 <br />No[es,^flemarks, Etc.r-------l- <br />ll[,fl702 w R ccE ,.9 J Dtr*4 -l <br />I J I