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PLUMBING.!NSPECTOR RECORD APPROVALS DATE ID/SIG,COMMENTS OWNER BUILDER DELCARATION I h@by affm unds p€nally of pdjury that I m qcmpt ftom thc ContracloB' Liccrc [rrv for thc following lwtr (Sc.70!1.5 Buinas and Prcfeion Codc): Any City or County which rcquirc a pcmit to coEtruct. ,ltq, improvc. dcmolish or rcpair my strucluc, prior to its isumce. also rcquiE the applicant for such pcnnit to filc a signcd stalmt that hc or shc b lica&d pwmt to thc provisiom of thc Coilractor's Licm*d Larv (Chapl6 9. Commcing rvith SBtion 7000 of Division 3 of thc Buins md Prcfesioos Codc) or that hc or shc is ampt thEcfrom ed thc basb for thc allcged cxmpion. Any violatiotr of Sdtion 7031.5 by any applicant for I pcmit sbjct! thc ap?licant to a civil pmlty of ml morc thil fivc hundrcd dollss (S500). -.1. as owner of the propefly. or my employees with wages as their sole compeflsation. will do the work and thc stnrcttre b not intended or offered for sale (Sec.7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of the progrerty who tuilds or improve thersrn. and who does such *'ort himself or hcrself or through his or her orvn cmployecs. provided that such improvanents arc not intfided oroflered for sale. lf. horver/s. the btrilding or improvonent is sold rvithin one )€ar of complaion. the Ourner Builder will have thc burden of p,roving thd hc or she did not build or improve the property for the purposcof sale). _-1. as o\\mer of the properly. am exclusively contracting rvith licensed contradors to construcl the poject (Sec. 7M4. Business and Profcssion Code: 'fhe Contractor's License Law does not apply to an owner of property rvho builds or improves thereon. and rvho contracts for such projects rvith a Contracto(s) licersed pumuant to the Contractor's Liccnse Law). -l am exempt under Section--. B. & P.C. for A lt A JrarI. v [, I I hereby affirm under penalty of pojury t)ti('LARA'l toN one of tlre follorving declarations: _l have and u'ill rnaintain a Ccrtificate of Consent to Sclf-lnsure for s'orkers' compensation. as provided for by Section -1700 of the l,abor Code. for the pcrfionnance of the rvork for rvhich the po'nrit is issued. _-l har,e and rvill nraintain u'orkers' compensation insurance. as required by Section .1700 of the Labor ('ode. for the perfonnance of the w'ork for rvhich this pennit is issued. My u'orkers' compensation insurance carrier and policy number are: Carrier: _-l certi$, that in the performance of the rvork for rvhich this perrnit is issued. I shall not onploy any person in any manner so as to become subject lo the u'orkers' compensation las's of California. and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall. forthrvilh comply rvith those provisions.. WARNING: Failure to secure lvorkers' compensation coverage is unlarv[ul. and shall subject an and civil fines up to one hundred thousand dollars ($l in addition to of the Section 3076 [.atror and attorney's l)t ('t.,\tt^ I t()N/ I hereby affrnn tunder penalty of perjury that I arn licensed under provision of Chapter 9 (commencing rvith Section 7000) of Division 3 of the Business and Professions Code. and nry license is in frrll force and effect l.icensc ('lass: l iccrrsc Nrrrtrltcr': llolp'( 'orrl rlcl rlr: W I horby affinn und6 pcnshy of pcrjury thd thsc is a consrrucrion hnding agocy for the pcfotrmcc of thc rrcrk for shich thb psmh b issued (Sec. 3097, Civ. C.). Lender's Name: Lcnder's Address: APPLICANT Df,CLARATION I ho*yallim undq turalty of pcrjury one of thc following dclarations: Dcmolition Pmits-Asbctos Notification Fcdoal Rcgulations (Titlc 40. Parr6) -Rcquir€d Lett6 of Notification -l cqtiry that the fcdaal rcaulatioro rcgarding rbstos rmoval are not applicablc to lhis prej61. - I cgtify that I havc rad this applicstion md stale lhst thc above infomation is cortrt. I agrcto mmply rvith all Cityand County ordinancd and Statc L.s s rclaling lo building coNtruclion. and hftby authorizc rcpMtalilc of this City md County to otq upon thc above rnentioned properly for Applicnnl or Agent Permilec nRme (print): UNDER GROUND Waste & Vent q-n4?l rL€Z .q Water-Under floor Gas-Underfloor Buildinq Sewer ArealStorm Drain ! nterceptor/ Cla rifier TOP OUT Waste & Vent Water Piping Gas Piping Roof Drain Tub/Shower Test Rough Water Heater POOL/SPA P-trap/Drain Line ItIain Drain/Pool Piping Fill Line/Back FIow Pool HeaterlGas Line Miscellaneous Gas Service Water Service Lawn Sprinkler Sanitary Sewer/Cap Back Flow Device 1 Rough Plumbins /oh llq ?t fi /cr/ Final Gas Test Meter Release 6D/ FINAL Notes Remarks Etc. F -2 Expires: 7tttffi N G,,", ?l16'/q ,olgsl,lta fiaruqya U