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PLUMB!NG.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNEN BUII,DER DETARATION <br />I hscby affm uoda pculty of pcjury ttd I m smpt fiom lhc CrdrrlN' Licw try for tlrc fo[owing rctdrit (S.c.703tt <br />Buhs md Prcfeion Codc): Any City or Courly which rcquiB r psmt to @Euuct, altc, imprcvq dcmolish or rpah ray <br />stuclucpriortoits irslmqd$rlquh6thcrylicmtforsuchFrnittofilcEligncdltdoqrt thtth.orCrcblimscd puman <br />to thc provbiom of th. Coob&ltr's Licas.d kw (Chapta 9, Comtring with Setior 7000 of Division 3 of thc Buim ud <br />ProfsiomCodc)orthdhcorlhcisqmptth@ftommdthcb6sbforthcallcgcdq@ptioo. AnyvhluiorofsEtb!703l.5byuy <br />spplicut for I pcrmit subjGts thc rpplimt to a civil pa8lty of mt mrc the 6vc hun&cd dollars (t500). <br />-1, <br />s oms of thc prcpqty, or my mplolE wiah weg6 s thcir slc ompaBdbn, will do rhc wL ad tlE dnnre b mt <br />inradcd or ofrcrcd for slc (Sc.7044. Buire md Profsioc Codc: Thc Cooaaq'r Lkre lrw do6 not eply to u ow of <br />thc FDpqty who builde or inproc tluurl. od who d6 grch rc* hiroclf or h*lf or thnud his or lE om cmploya. <br />prcvidcd that such imprcwrats rc mt intadod or oltrcd 6r sh. lf, how, thc hrildirg or ir4rowmt b mld within orc )a <br />of onphb+ thc Ovm Buildc will ]urc tlE hrda of poving thi hc u dE did not hrild u irqrow tbc popoty 6r th prpos of <br />sb). <br />-1, <br />s oma of thc Fopsty. m qcluiwly coltncliru with lifficd @atrlcloB to oNtruct thc Fojet (Sc. 7044, Buin6 <br />and Pmftsin Co&: Thc Contrelor'r LicGN Lsw do6 mt eply to m owa of propaty who buikls or inprovG th6on, <br />ud who @nFets for iEh Foj*rs with . Codractq(s) lLrEcd pmuot to thc Conbelor's Liffi [rw). <br />-l <br />m crmDt und( S61ion-, B. & P.C. for this @tr. <br />WORKERS' COMPENSATION <br />DECLARATION <br />I hereby affrrm under pcnalty of perjury one of the following declarations: <br />_l have and will maintain a Certificate of Consent to Self-lnsure fior workers' compensation. as provided for by Section 3700 of the <br />Labor Code, for thc pcrformance of the work for which the perrnit is issued. <br />_l have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code. for the pcrformance of <br />the work for which this pennit is issued. My workers' compensalion insurance carri€r and policy numk are: <br />Carrier: <br />_l certi& that in the pcrformance of the work for which this permit is issued, I shall not cmploy any person in any mann6 <br />so as to become subject to the workcrs'compensation laws of California, and sgree that if I should become subject to the <br />workcrs' compensation provisions of Section 3700 of the labor Code. I slnll. forthwilh comply with thosc provisions.. <br />WARNING: Failure to secure workers' compensation coverage is unlawful, and shall subject an snployer to criminal panhics and <br />civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of compensation. damages as providod for the <br />Section 3076 of the Labor Code interest and attornsy's fees. <br />Dnte: Applicent: <br />LTCENSED CONTRACTOR <br />DECI.,ARATION <br />I hereby affirm under pcnalty of perjury that I am licensed under povision of Chaptcr 9 (commencing with Section 7000) of Division 3 <br />of the Business and Professions Code. and my license is in full force and effect. <br />License Class:- Liccrse Numbcr: <br />I)o I o' <br />CONSTRUCTION LENDING AGENCY <br />of perjury that there is a construction lending agency for the performance of thc work for which this pcrmit is <br />Lender's Address: <br />APPLICANT DECLARATION <br />I her*y affrnn under penalty of perjury one of the following declarations: <br />Dernolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) <br />-Required <br />Letter of Notilication <br />_l certi& that the federal regulations regarding asbestos removal arc not applicable to this project. <br />_l cqriry thal I havc ud this application ud statc thd thc sbove iofomation is cor*l. I agc to smply whh all City md County <br />ordimncG ud Statc kws rchting to hilding construction and h6cby authorirc rcTr6otativ6 of this City md County to mt6 upon thc <br />8borc motioncd pppsty for iNpcdion purpos6. <br />Applicsnt or Agmt SiSmturc:_ Drlc:_ <br />l'crlrrilct, n:unc ( ;lrirrt ). <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />ArealStorm Drain <br />I nterceptor/ Clarifier <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 Flow <br />Pool Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary SewerlCao <br />Back Flow Device <br />Roush Plumbins <br />Final Gas Test <br />Meter Release I t1 ,o <br />FINAL \rfffr <br />Notes, Remarks, Etc.I' <br />Policy Number:Expires: