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PLUMB!NG-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby sffrm under Fnrlty of lrcrjury thll I m ercmpt ftom the CootrrctoE Licus hw for the folhwing mrco (Se.7O3?.5 <br />Busircss ard Profession Codc): Any City or Couily which rcquircs a pcmh to snstruct, alt6, iqmw, dcmlish or Ep6ir any <br />struclurc. pri.,r to its rssum. sls rcquircs llrc rpplicsnt for such pcmit to filc s sigrcd slalcmil that hc or CE is lisroed pwsnt <br />to thc pmvisions of thc ContBctor's Licensd lrw (Chaptcr 9. Comercing wilh Sstion 7000 of Division 3 of the Busiress rnd <br />PrcfcssionsCode)orthathcorsh€iscrcmptthcrcfromandthcbasisforthcalhgedcxemplion. Anyviol8thnofSathnT03l.5byany <br />applicantforspermilsubjEtsthc applicsnltoacivilpenrllyofnotmrcthanfivchundrrddolles($500). <br />-1. <br />as owncr of the propcrty. or my cmployees with wagcs as thcir sole comFrcnsation. will do thc work and the structune is not <br />intcndcd or offcred for salc (Scc.7(}14. Busincss and hofcssions Code: The Contractor's Liccnse law docs not apply lo an owncr of <br />lhe propcrty who builds or inTrrovcs therenn. and who dcrcs such work himself or hcrself or through his or hcr own employccs. <br />providcd that such improvcnrnts are not inlendcd or offercd for sah. lf. howevcr. thc building or itrprovenrnt is sold within one ),ear <br />of co:nplction. the Owncr Buildcr will have the burdcn of proving that hc or shc dkl not build or improve the propcrty for lhe purpsc of <br />sah). <br />-1. <br />as owner of thc propcrty. am cxclusively contracting with licensed contractors lo conslrucl the projcct (Sec. 7W, Business <br />and hofcssion Codc: Thc Contraclor's License Law docs not apply lo an owner of prolrcrly who builds or improves thercon. <br />and who contracts for such projccts with a Conlracto(s) liccnrcd pursuant lo lhe Contraclor's License hw). <br />-l <br />am cxcmpl under Scction_. B. & P.C. for lhis rcason. <br />I)tlc ( )rr rrt r: <br />WORKERS' COTVIPENSATION <br />DF'CLARATION <br />I hcrcby alf irm undcr penalty of pcrjury one of the following dcclarations: <br />-l <br />havc ancl will mainlain a Ccrtificatc of Conscnt to Sclf-lnsurc tbr workcrs' conrpcnsation. as provided for by .Scction 37fi) of thc <br />Latxrr Crxlc. for the Jrcrfonurncc of thc work lbr which thc pcrrnit is issucd. <br />-lhavcandwill <br />maintainworkcrs'cornpcnsationinsurarrc.as rcquircdbyScction3T(X)ol'lhcLaborCodc.forlhcpcrformanceof <br />the work lbr this pcrnrit is issucd. My workers'carricr and Jmlicy nunrber ure:\ <br />Policy L o <br />a <br />-l <br />ccrtify that in the pcrformancc of thc work for which this prmit is issued. I shall not cmploy any person in any manner <br />so as lo hecomc subpct to thc workers'compcnsation laws of California. and agrce that if I should beconre subject to thc <br />workcrs' compcnsation provisions of Section .170O of thc Labor Code. I shall. forthwith conrply with ttrose pmvisions. <br />IVARNING: Failure to securc workcrs' cornpcnsation covcragc is unlawful. and shall subjecl an cnrploycr to crirninul Jrcnaltics and <br />civil lincs up lo one hundrcd lhousand dollars ($1ffi.ffiO1. in addition to thc cosl of com;rcnsation. damagcs as provided for the <br />.Scclion .107(r ol'thc Latxrr Crxlc. irrlcrcsl arrd tu r\t*",.\>h{ (l \<. <br />I hcrcby nllirm undcr ;rcnalty of pcrjury that I am liccnscd 9 (comnrcncing with Scction 7(Xru) of Division .1 <br />of thc Busincss and Professions Code. and my licensc is in full forcc and cffcct. <br />1 \rrq 6? (o <br />Licc-nsc <br />l)ale:I qrLct tt,n <br />W <br />I hcrcby allirrn undcr pnahy ofpcrjury thut thcre is a construction lcnding lgcncy for lhc lrcrfornuncc oflhc work for which this lsmit is <br />issucd (Sa. 3097, Civ. C.). <br />kndcr's Namc: <br />- <br />lrndcr's Addrcss: <br />APTLICANIJEGI.ABAIITN <br />I lmtryaffrmundcr pcnalty of ;rrjury onc of thc following dslsrations: <br />Dcmolilion Pcrmils.Asbestos Notificstion Fcderal Regulations (Titlc 40, Pad6) <br />R@uircd Lttcr of Notifi cetion <br />--l <br />c(dify that thc fcdcral rcguhlions rcguding a{rstos rcm)val arc not applicabh to this Jrojsl. <br />{-l cmify rhat I haw rerd this applicalion and statc that thc abovc information is cor6t. I agG to omply with rll City and County <br />ordinares snd Strte [rws rclating to buildin8 construclion, ud hcrcbyauthorirc ]cJtrcscntativcs of this City and Countyto cnts ulhn the <br />abovc mcntioncd proprty for <br />Apgrlicant or Agenl <br />Pernritee n$nre <br />UNDER GROUND <br />Waste & Vent ,l I <br />Water-Under floor 0lttlt4 T)A,{V)4.*N '1 <br />Gas-Underf loor t l-\r <br />Buildinq Sewer <br />ArealStorm Drain <br />I nterceptor/ C Iarif ier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />N/ain Drain/Pool Piping tzl Bl nj NYq-*4t1 <br />Fill Line/Back Flow I <br />Pool Heaterlcas Line <br />Misce!!aneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewerl3ap <br />Back Flow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release I rl A. <br />FINAL qYLhl ln Dku.nd .-xgl <br />arks Etc <br />lol -?Lvrut6 r| -- D4 <br />rJr 6,-- -, <br />rv) tt -fl nI,0n <br />e