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PLUM BING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNERBUILDERDELCARATION ,I hcrcby affirm undcr pcnalty of pcrjury lhal I m cxcmpt from thc Contmctom' Licens kw for the followint rcarcn (Sc.7O3l5 <br />Business and Profession Code): Any City or County uhich rcquircs a Jrcmit to construct. alts. imprcrc, dcmliih or rcltir qi <br />slructuE. pri)r to its issumc. slrc rcluircs thc Epplicsnt for such tEmit lo lih I signcd statcmnt thet he or shc is lienrcd pusuut <br />to thc prcvisions of the Contrsctor's Liccnsd [:w (Ch.ptcr 9. Comrcrcing wilh S6tion 7U)0 of Division 3 of the Busiress md <br />PrcfessionsCode)orthatheorshcisexcmptthrefromsndthcbasisforth€allegcdexemption. AnyviolationofSelionT03l.5byany <br />spplicant for s Jf,mit subjsts thc applicsnl to I civil pcnllty of mt mrc than fivc hundrcd dollus ($5fi)), <br />_l.as o\l'ncrofthcpropcrty.ormyenrployccswilhwagcsasthcirsolccornpcnsalion.willdolhcworkandthcslnrlurcisnol <br />intcrrdcd or ()fll'rcd lbr salc (Scc.7(X4. Busincss and Prol'cssions C<xlc: 'l'hc Contrircl()r's Licensc l-nw docs nol apply lo an owncr of <br />lhc prnprly u,lxr builds or itnprovcs tlrcrcon. ilnd who drrcs such work hirnscll'or hcrsclf or lhrough his or hcr own cmployccs. <br />provided thal such improvcnrcnls are nol inlcnded or ofl'crccl for sak. Il. howcver. lhc buikling or irnprolernent is sokl within onc ycar <br />of cornpletion. thc Owncr Buiklc'r *'illhavc thc hurdcn of proving that hc or shc did not buikl or inprore thc propcrty for thc purfnscof <br />srhl. <br />_1. us owncr of the propcrly. arn cxclusivcly contractirrg with liccnscd conlractors lo conslruct lhc projccl (Scc. 7(44. Busincss <br />arrl [tofcssiotr C]odc: Thc Contr:rclor's l-iccnsc Law docs not apply to .ur owncr of propcrty who huilds or improves lhercon. <br />an(l who conlracts ftrr such projccts with a Conlraclor(s) liccnscd pursuanl to lhc Conlractor's Liccnsc Law). <br />_l arncxcnrt)l urrdcr Sccti<ln_. B. & P.C. Iilr lhis rcason. <br />l )alt :Owner:_ <br />W(IRKF'RS' COM PENSATION <br />DECLARATION <br />I hcrcby affirm under pcnalty of pcrjury onc of the following declarations: <br />-l <br />have and will maintain a Certificale of Consent to Self-lnsure for workers' compensalion. as provided for by Section 3700 of the <br />I-abor Code. for thc performnncc of thc work for which the permit is issucd. <br />-l <br />havc and will nraintain workers'cornpcnsation insurance. as requircd by Section 37fi) of the Labor Codc. for thc pcrformnncc of <br />lhc work f'or which this My workers' conrlrcnsation insurancc carricr and plicy numher arc: <br />Policy <br />-l <br />certify that in the pcrformance of thc work for which this Jrcrmit is issued. I shall not employ uny frcrson in any manner <br />so as lo bcconrc subjcct to thc workers'compcnsation laws of California. and agrce lhal if I should bccomc subjcct to thc <br />workers' co:npcnsation provisions of Section 3700 of thc latnr Cocle. I shall. forthwith comply with those provisions.. <br />WARNING: Fuilurc to sccurc workcrs' conrlrcnsation coverage is unlawful. and shall suhject an employcr to criminal pcnaltics and <br />civil fincs up lo onc hundrcd lhousand dollars (SlOO.Un). in addition to thc cost of providcd for thc <br />.Scclion 307(r of atlorncy's fccs. <br />I hcrchy affinn urtdcr pcnalty ol'perjury thal I am liccnscd 9 (colnnrcncing with Section 7fin) of Division 3 <br />of thc Busincss and Pmfcssions Code. und nry licensc is in full force and elfcct. <br />[,iccnse Nurnbcr:/r/4?zt <br />lhcrcbylffir[lundcrFnultyofpcrjurythil,nffi*-*,**,n*,*,**,,n,*"*rfonnonccofthcworkforwhichrhisIErmitis <br />issucd (56. -1097. Civ. C.). <br />[andc]'s Narc: <br />l.ctttlcr's Adrlrcss: <br />APPLICANT DECT ARA'IION <br />I hcrchy alfirnr urrdcr pcnalty of prjury orrc ol'lhc lblkrwing dcclarations: <br />Dcrnolit ion Pcrrnils- Asbeslos Nol ificat ion Fedcral Rcgullt ions (l'itlc 40. Part(r) <br />-Rcquircd <br />[.ctlcr of Notificalion <br />-l <br />ccrtify lhat thc fcdcralrcgulations rcgarding asbcslos rcmovalarc not applicablc to this projcct. <br />_l ccrtify that I havc read this application and slate that lhc ahrvc inforrnalion is corrccl. I agrce to conply with all City and County <br />abovc mcnlioned pro5rcrty for ins;rc.ction <br />Applicnnt or Agenl <br />I'ernrilee nanre <br />of this City and to cnler uJxrn thc <br />UNDER GROUND I <br />Waste & Vent lrt < llg Dftnn fl-*Y1 <br />Water-Under floor lt I <br />Gas-Underf loor I lA <br />Buildinq Sewer th '*al w 'IMUCIfst 4aQy <br />ArealStorm Drain t <br />I nterceptor/ Clarif ier <br />TOP OUT I <br />Waste & Vent l(.?41 tl D+-/ll6L <br />Water Piping tlA-tutlr rwy? <br />Gas Pipinq w,*vrr-"r -*9 <br />Roof Drain I I l, <br />Tub/Shower Test />An1a ? *l- y7 <br />Rough Water Heater I tt <br />POOL/SPA <br />P-trap/Drain Line <br />N/ain Drain/Pool Pipinq <br />Fill Line/Back FIow <br />Poo! Heaterlcas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary SewerlCao <br />Back Flow,Deviee I ..4' <br />has4ts\ Lapvrru,)fit 1,xallt l )EPt tN,F w <br />Hbuqh Plumbinq I <br />Final Gas Test o DA AOt &ffi <br />Meter Release ,,I <br />FINAL I wa Dtfu>r Lff7VtlNotes, Remarks, Etc. <br />a <br />Carricr:- <br />Date:_Contraclor: <br />ordinances and .Statc [^aws rclating to building construction.