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PLUMBING.!NSPECTOR RECORD <br />DATE ID/SIG.COMMENTSAPPROVALS <br />UNDER GROUND 7()r:F frWaste & Vent q.l <br />IWater-Under floor JI <br />Gas-Underfloor <br />a-Building Sewer <br />,ArealStorm Drain <br />I nterceptor/ Cla rifier <br />ITOP OUT <br />/'it ?t ,7 Dr?f6Waste & Vent 4Water Pipinq c <br />t T <br />Gas Piping <br />Roof Drain frTub/Shower Test l0 <br />tRouqh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />Itlain Drain/Pool Piping <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />?i)DI,-rfl <br />41 rtWSanitary Sewer/Cap 8r <br />[-t'Back Flow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release I I <br />FINAL It <br />O\\'N Illl llt I I l.l)l!lt <br />I hrcby aflirm unda pmahy of pcrjury lhal I fln creinpt froor the ConlrackrE' l-icmr l.a$ for thc follosing rea$n (Ss.7oll 1.5 <br />Businss and profssion Code): Ant City or County $'hich rcquirs a lnrnil to conslntct. aho. improle. donolish or repair any <br />slructure. prior to its isuancc. also rcqtrirB the applicant frrr such frcmril to file a signcd statqnflt that he or she is licms.d pu6uant <br />lo the ptnvisiors of the ('ontractor's l-icensed l-as (Chaplo q. Comrnencing rvith ScIion 7000 of Division 3 of the Rusinss and <br />profcssionsCo<!e)ortha(heorshciscxemptlhtrefronandtlrclEsisfortheallegederonption. An1'violalionofsetionT0:ll.5byanr- <br />applicantforaJmnitsubj$tslhe applicanltoacivilpenaltyofnolmorelhanfir'e hundre<ldollusl$500)' <br />I. ns trs,ns of the proIE ty. or my cDplolG s ith s ags as their srle comp€netion. s ill do the lr'ork ud the stnldue is not <br />intcrrdd oroffcredfoiytc(Se.loln.g,'"insandPrcfsbns(\xte:The(onlrlclor'sl,iccnscl-a$'dosnolapplytoano$noof <br />the polErty $.ho huikh or imprer'c thmn. md vho do6 such srrd< hirnself or ltmelf or thrcugh his or he orvn cmployec. <br />p,oui.li.,lrhat"u"h irnftrormfllsrcnotintfldedoroJfq.dfor$le. lf.ho$66.thetitildirgorimpmtonmtiswldtithinonclm <br />irfconrplait'n. rhe (hvnq Ruilds s ill harc the hurds ofproling that hc or she did mt ttild or irnJnrle lhe lmJury for the prrym of <br />sale). <br />l. as osns ofthc popqtl. am erchrsilely contracting $hh licsBcd conlraclors kl conslntct llrc prejcl (Ss. 7O14. Bminess <br />aod ttofssiotrCode:'lheContractor'sLicensel.aNtlomnolapplytoanoNnsofproftstlN'hobuildsoritnprotGths@n. <br />and rvho contracts for such projects rvith a licensed pursuant to the Contractor's License Law).\ <br />-l <br />am exempt under Section-for this <br />l)nlt: <br />I ho'eby alTirtn under <br />I have and s'ill mainrain a Cerri-frcate of Consent ro Self-lnsure fior rvorkers' cotnpcnsation. as provided for by Section -]700 of the <br />l-atxrr ('ocle. for the gro'fonnance of the srrrk frrr s'hich the pornit is issued. <br />_thayeandrvill nraintainrvorkers'qpnrpensationinsurance.as requireclbl'sectionlT()0ofthcl.ahor('odc.fortheperfonnanceol' <br />the g.ork for rvhich rhis perrrrit is issued. IVly rvorkcrs' cornpensation ittsurance can'ier antl policy ntttntrer are: <br />Carrier: <br />Policy Number:- <br />_l cediry that in the per-formance of the rvork for rvhich this permit is issued. I shall not employ any Person in any manner <br />so as to become subjeci to the rvorkers' comporsation laws of California. and agree that if I should become subject to the <br />work€rs' .orp.nrriion provisions of Secrion -1700 of the Labor Code. I shall. forths'ith comply with those provisions.. <br />\1'ARNIN(l: f;ailure to sectre s'orkers'covera8e unlas'lirl. antl shall subiect an onployqr to criminal poralties and <br />comgrcnsation. ahug* ., pror:icled for thecivil fines up lo one hundred thousand dollars to the cost of <br />Section -1076 of the Latxrr Code. interest and <br />I hereby affirm under penalty of perjury I arn provision of Chapto 9 (comrnencing rvith Section 7000) of Division J <br />of the Business and Professions Code. and my license is in full force and effect. <br />l.icense Class:_- <br />-License <br />Nutnber: <br />l)nlc ('oltlrnctol': <br />(:ONSTRUCTION LENDING AGENCY <br />I hotby aflirm undo 6naltyof poi,,rythat thil immction lcnditg agqrcy forlhc perfomance of lhervork for Nhich lhis Pmnh b <br />issucd (Sc. .1097. Civ. ('.). <br />I t'ntlt't's \ltttte <br />Lcnder's Address: <br />APPLICAN'T DEC LARA'I'ION <br />I hoelry aflinrt under penalty of perjury one of the follos'ing declarations: <br />Dernolition Perrnits-Asbestos Notification Fcderal Regulations ('Iitle 40. Pafl6) <br />- Required Lctter of Notification <br />_t removalare not annlicatr\o this project. <br />lccrlifr <br />ordinances <br />above mentioned <br />Applicant or <br />Permitee name <br />infiornration is conect. Itr1 >4 <br />-UG I <br />7 <br />'4t|ru,, <br />10, <br />I <br />I <br />7 <br />Date: <br />with all City and County-w <br />Date: <br />,-WtdU <br />Notes. Remarks. Etc. <br />Yr &,#,il 6refu <br />d(P <br />(,