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-PLUM BI NG.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG GOMMENTS OWNI:R BUILDT:R DELCARAT'ION ' ! . <br />I hereby allirm under pemlty ofperjury rhat I am excmpt fmm the Contractom' License Law for the following reamn (Sa.?0115 <br />Irusincss aRl Profcssion Code): Any Cily or Counly which rcquires a pennit lo mnsrucl, alts, improvc, demolish or repoir any <br />slructurc, prior lo ils issuamc, also requircr the applicanl for such pemit to file a signed statcmcil that hc or she is licenscd pumanl <br />to rhc previsions of the Conrractor's Liccnsed Law (Chapter 9, Commercing with Section 70fi) of Division 3 of thc Busincss and <br />PmfessionsCode)orthathcorshcisexemptlh€rcfmmanddEbasisfortheallegedcxemption. Anyviolationofs*lion703l.5byflny <br />applicantforapcmitsubjststhc applicanttoacivilpemltyofnolmorethanfirehurdrcddollds(5500). <br />_1, as owncr of the prepcny, or my cmployecs with wages as their sle co[pen$tion, willdo lhc mrk arxl lhe srctm is mt <br />intended or olltrcd for sle (Sc.?(X4, Business and Pmfessions Code: 'l he ('ontractor's Liccns Law does not apply to an owrcr of <br />thc pm;Efly u,tn builds or impms th€mq and wtr (kB och uort himself or hemlf or thmugh his or hcr o*n cmploycs, <br />pmvidedthatsuch impmvmntsmmtiilcrdedoroflirrdforslc. l[ln*crc.thchuiHingorimpmvemflissHwilhinoncyqr <br />of srnl,letiorl th€ CXtrrcr Builder will havc the hurden of pmving thal he or she did mt build or iqtmE the pm]tny for lhc PUrJD* of <br />sle). <br />_1. as ouner of the pmp6rty, am exclusivelycontracting with licensd conlraclon to q)nsrucl th€ pmjst (Se. 7044, Business <br />an PmftssionCode:-lhcConlractor'sl-iccnscLawdoesmtapplytoanou'ncrofpropenywhohuildsorimproveslhcrsn, <br />and who mntmcts for such prcjects wi(h a Contmcto(s) licensd puFunt lo lh. (lontrsctor's Liccnsc l-aw). <br />-l <br />am exempl under Section-, B. & P.C. for this reavtn <br />Owner:_ <br />WORKERS' COM PENSA'I'ION <br />DECLAIIA'I'ION <br />I hereby alTirm under penahy of perjury one of the follou'ing declarations: <br />_l have arxt will maintain a Certificate of Consent to Self-lnsure for workers' compensation, as provided for by Section 3700 of tlre <br />[-abor Code, fur the perfonnance of the work ft)r which the permit is issued. <br />_l have and witl maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the perfurmance of <br />the work for which this permit is issued. My workers' compensation insurance carier and policy number are: <br />Policy <br />_l certi& that in the performance of the work for which this permit is issued, I shall not employ any person in any manner <br />so as to become subject to the workers'compensation taws of California, and agree that if I stnuld trecome suhject to lhe <br />workers' compensation provisions of Section 3700 of the Labor Code, I shall, forthwith comply with ttnsc provisions.. <br />WARNTNG: I;ailure to secure workers' compensation coverage is unlawful, and shall subject an employer to criminal penaltie's and <br />civil fines up to one hundred thousand dollars (St00.000), in addition to the cost of compelLsation, damages as pmvided for the <br />Section 3076 of the Labor Code, interest and attorney's fees. <br />I ICI.'NSED CON'I'RACI'OR <br />DECLARATION <br />I hercby aflirm under penalty of perjury that t am licensed under pnrvision of Chapter 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: License Number: <br />('ottl r:rcl ot' <br />W <br />I hercby aflirm under pcmlty of perjury thot thse h a construclion hrding agcncy for th€ pcrfomrcc of the work It r which lhis Frcmil is <br />issucd (Ss. 3097, Civ. C.). <br />Lender's Name: <br />APPI ICAN'T IIECI ARA'TION <br />I heneby aflinn under penalty of perjury one of the folltlwing declaratittns: <br />Denrolition Permits-Asbestos Notification l;ederal ltegulations ('l'itle 40, Part6) <br />-Required <br />Letter of Notification <br />-l <br />cenify thot the federal rcSulations Egarding asbcrlos removal trrc mt applicable to this pmjst. <br />_l cedify rhd I harc rcad Ihis applicarion ard state lhat the atnve infomtion is coret. I agrc lo omply with all City ard County <br />ordinarcs and SIate Laws rclating to building co[dructior\ {d hcrebyaullnrize repffintatilts of this Cilya]d Countylo cnls uF n lhc <br />atnvc mntioncd pmpeily for inspcction purlnss. <br />Applicant or Agent <br />l'erlrritct' nilnre (llrirrt) : <br />Date:_ <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 Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rouqh Water Heater <br />POOUSPA <br />P-trap/Drain Line <br />Main Drain/Pool Pipinq <br />Fill Line/Back FIow <br />Pool Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary SewerlCap <br />Back Flow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release <br />FINAL t tbl?,,)D ftyy)7LtrTA <br />Notes, Remarks, Etc.IU <br />Date:_ <br />Carrier: <br />-Expires: