30137540 - Permit - Laserfiche WebLink

Home Browse Search

APPROVALS DATE ID/SIG. UNDER GROUND / Waste & Vent Water-Under floor PLUMBING-INSPECTOR RECORD COMMENTS OWNER BU ILDER DELCA RATION I hereby a ffirm under penalt y ofpe1ju1)' thnt I run e:xcmp t from 1he Co n1r.ictors· License La w for lhe followin g 1·enso n (Sec.703 1.5 • Ousiness and Pro fession Code): Any Cit y or County which requires a pcnnit to cn11stn1ct, a lter , improve. demolish or ,repair any s tructure . prior to its issuanc e. a lso requires the app li canl for such pennit to file a signed stntcment thm he or s he is licensed pursufmt to the provis ions o f the Contrnctor's Licensed La w (Chapter 9. Commencin g with Section 7000 of Division 3 of 1h e 13usiness and Professi o ns Code) or that he or she is exempt therefrom and the basis for the all eged exemp tion. Any violnt ion of Section 7031 .5 by any applicant for a permi t su bj ects th e applican t to a civ il penaltyofnot more th an fi ve hun dred do llars ($500). Gas-Unde rfloor _r. .is owner or1hc pro pe1ty. or my em ployees w ith wages ilS th eir sole compcns.u ion. w ill <lo the w or k and the st rui:llwc is not intended or offered for sale (Sec.7044. Business and Pro ressions C'ode: The C'o ntn1 ctor ·s License Law d oes not apply to an {lwner of Bui Id i nq Sewer the property who bu ilds or improves thereo n. and who docs such work hi mself or hersel f or through hi s or her own emp ](lyees. provided tha t such improvements are not intended oron'ered for sale. Jr. however. the building or improvement is so ld wit hi n one year Area/Storm Drai n of co mp letion . the Owner Builder will have the burdt.'n o f proving Ihm he or she did nOI build or impro,·e lhe pmpe11y fort he pllllX)SCof t-l_n_t_e_r_c_e_i~pt_o_r /_C_l_a_r_i_f _ie_r ______ --lf---------+---------+--------------------1~ as owner o f t he propct1y, a m exclus ive ly contracting w ith li ce nsed contractoi, to co11st111ct the proj ect (Sec. 704 ,1, Ou,incss \. VU-Pro rcssio n Code: The Co111rnctor·s Lic en se Law llocs nol apply to mi owner o r property wh o buikl s c1r imprtH·cs thcrctin. TOP OUT Waste & Vent Wate r Piping Ga s PipinQ Roof Drain Tub/S hower T est Rouqh Water Heate r POOL/SPA P-trap/Drain Line , Main Drain/Pool PipinQ Fill Line/Back Flow Pool Heater/Gas Line Miscellaneous Ga s Service Water Service Lawn Sprinkler Sanitary Sewer/Cap Back Flow Dev ice ... h1 Rough Plumbing Final Gas Test V ( \_./ Meter Release FINAL Notes, Re marks, Etc. a nd w ho contracts for s uch projects wilh a Co11trn cto1~s) licensed pursu.mt to the Contrnctor ·s License Law). _I run e xempt uJ der s.7_11011 ~· B~ rnr t l~·eason_:_ / Date • / / //,,, // f/7 Own er:~~ --~ ~ ( l """"woii"KERS' CO1\l l'ENSA TION DEC L A RATION I he reby affi r1n under penalty of perjury one of 1he fo llC>wing dcclarnt ions: _I have nnd wil l maintain ,1 Ce11ific:ue of Consent 10 Self-I 11s11re for workers ' co111pensntion. ns pro\·idcd for by Section 3700 o f t he Labor Code. for th e pcrfonnance of th e work for which the pcnnit is issued. _I have and wi ll maintain worke rs · compensation i11surance. as required by Scrt ion 3700 nf the Ln bor Code, for 1he performance o f the work for whic h this pcnnit is iss ul.'d. My workc.1'5· compcnsntion ins urance c.:11Ticr am.I policy mnn bcr are: Ca.Tier: __________________________ _ o I Numbcr: _____________________ Expircs: __________ _ ce11ify tha t in th e performance oft he wo rk for whi ch this per mit is issued. I shall not employ 1111y person in any nrnnncr s o as lo become subject to lhc workers' co mpensation laws orCaliromia. anti agree that if I sho uld become subject to the workers' compensati on prov isions o f Sectio n 3700 of th e Labor Code. I shall. fo11hwith CC'lmply with those prodsions .. WARNING: Failure to secure workers' compen satio n covern ge is unlawful. and shall su bject an employer lo crimi n<1I penalties and civil fi nes up to one hundred thousand do ll ars ($100.000). in addition 10 the cost of compensat ion. damages as provided for th e Sectio n 3076. <;.L!j i~abor ~c. interest and all omcy 's fees~-/!~.: _ = ~ _ Dale: / d/6?///4 A 1i 1i lica11t : ~~ ~ ( ( -T LICEN ') 'ON TRACTOR D ECLARA TION I he reby affirm un der penahyof pe1jur y that I am licens ed under IH·ov is ion of Chapter 9 {commencing with Seel ion 7000) c,flJivision 3 of the Business and Profess ions Code. and my license is in fu ll force and cfTcc t. License Class: ______________ Liccnsc Num ber: _______________ _ Date: ___________ Conln1cl or: _____________________ _ C ONSTRUCTION LENDING AGEN CY I hereby affirm under pena lty of perjury th .11 there is a constmclion lendin g ;ige ncy fo r the pe:rfon nance of1 he work for which this pennil is issued (S ec. 3097. Civ. C.). L cndcr ·s N nmc: _________________________ _ Lende r·s Address:------------------------~- APPLICANT DECL A RATION I hereby nffi1m under pen nh y of perj ury one of t he follow ing declarmions: Demolitio n Permit s-Asbestos Not ificat ion Federal Reg ul ations (Tit le 40, Pm16) _Required Let ter of Noti fication I cet1 1fy that th e fcd ernl 1ci;ulatmns 1cgmdm g asbestos 1c rnoval me not appl1c.iblc to this project i--------------------f---------+--------+------------------A---\,...e.l c111fy th at I hme read tins appli cat1on and state th at the above m fommticm 1s conect I agree to compl y w1th .tll C11y ,111d Coun ty ' ces and State Laws relating to butldm g. constme11on. and he,cby nuthow.e 1cp1csentnt 1vcs ofth1s C1ty and Cou111y to enter upon the above mentio ned prop e11y for mspectlo n ~)' ,_.._ '/? .J' _ _£,,__ ~,, ~ -// / A p1i licant or Agent Sig nalnre: 7' "{ A _,_,, ~ ~--D,lte ' / 'c:;, L£-b P ennitee n a m e(print) X / /_. ~ 'i t.LV ~~~Y--C::::, ( • V ///) .?'"