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PLUM BING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby afftrm undcr pcnolty of pcrjury thal I m exempl fn m Ihc Contmclo$' Liense kw for the following rc&sn (Sbc.70-11.5 <br />Business and Profcsskrn Codc): Any City or Counly which rcquircs s Jf,rmit to onstruct. 8lts. imprcve, demlish or Epeir 8ny <br />structurc. Irior to ils issuuncc. rlso rcquircs lhc o0plicant for such Frmit to fih a signed slstemnt thst hc or slrc k licenred pmusnt <br />to the Eovisions of thc Contructor's Licensd [{w (Chaptcr 9. Commncing wilh Sction 7fi)0 of Division 3 of the Busircss and <br />PmfcssionsCodc)orthathcorsheiscremptthmfromandthcblsisforthealhgcdcremption. AnyviolationofsetbnT03l.5bysny <br />applicanlforapcrmilsubjclsthc opplicanttoscivilpcnallyofnotmrcthanfivehundreddollus($500). <br />-1. <br />as owner of thc propcrty. or my cmployces with wagcs as thcir snlc compensation. willdo lhc work and the structurc ls not <br />interrded or offcrcd for sale (Scc.7044. Busincss and hofcssions Code: The Contractor's License hw does not apply to an owner of <br />thc propcrty wtxr builds or inqrroves thereon. and who dcrcs such wo* hinrself or hcrsclf or through his or her own employees. <br />provided that such impnovenrcnts arc rtot intendcd or offered for sale. lf. howevcr. thc building or inqrmvennnt is sold within one )rar <br />of comphtion. thc Owncr Builder will have the burdcn of pmving that hc or she dkl ncrt build or improve the property for the purpse of <br />salc). <br />-1. <br />as owner of the propcrty, am exclusively controcting with licensed contractors to construct the pojc.ct (Scrc. 7W, Busfuress <br />attd Prcfessirn Code: The Conlractor's License [.aw does not apply to an owner of property who builds or improves thereon. <br />and who contracls for such proicts with a Contracto(s) lhensed pursuant to the Contractor's Licensc law). <br />-l <br />amexempl under Section-. B. & P.C. for this reason. <br />l)tlt, ( )rr ltt.r <br />WORKFRS' COMPF'NS {TION <br />DF'CL^ RATION <br />I hcrcby affirm undcr grcnalty of pcrjury one of the following declarations: <br />-l <br />have and will maintain a Certificate of Consent to Self-lnsurc for workers' compcnsation. as provided for by Section 3700 of the <br />l-abor Codc. for the performance of thc work for which thc permit is issued. <br />-l <br />havc and will maintain workcrs' c<lnrlrcnsation insurance, as requircd hy.Section <br />which this permit is issucd. My workcrs' comlrcnsation insurance carrier <br />3700 of thc l-abor Codc. for the pcrformance of <br />and policy number are:work frrr <br />(n"ri.r 1 q lys\r^,I <br />-l <br />ccrtify that in lhc prforrnarcc of thc work for which this perrnit is issued. I shall not cmploy any Frcrson in any manner <br />so as to bcconrc subjcct to the workcrs' compcnsalion laws of California. and agrcc that if I should bccome subjcct to the <br />workers' compcnsation pmvisions of .Scction 37fi) of thc [atxrr Codc. I shall. forthwith comply with thosc provisions.. <br />WARNING: Failurc to secure workers' comJrcnsalion covcragrc is unlawlul. and shall suhjccl an employer to criminal grcnaltics and <br />civil fincs up to onc hundrcd thousand dollars ($1m.000). in addition to thc cost of compcnsation. damages as provided for the <br />Sccliort 3076 ol'lhc Code. intercst and attorncy's <br />\ <br />I,ICENST.:D CON'I'RA C'I'OR <br />DUCI {RA'I'ION <br />of thc Ilusirtcss atttl ['rofcssions (irrlc. and rtry liccrrsc is irr firll lirrcc urrtlcllcct. <br />Ntttttl-o*r:6c>jYb1\ <br />('ontraclrlr: <br />W <br />I hcrcby aflirm undcr Fnollyof Frjury thal lhcrc is u constructinn lcnding agency for thc Isfonmncc of thc work for which this ]Emil is <br />issucd (Scc. 3097. Civ. C.). <br />kndcr'* Numc: <br />Lcrtdcr's Address: <br />AELIqANI.DECI.ASADON <br />I My oftmundcr lrcnrlty of perjury onc of lhe following dslarations: <br />Demlilion Permits-Ashcsros Nolification Rdcrol Regulations (Tillc 40, Part6) <br />-Rcquircd <br />[xtlcr of lhifi calion <br />-l <br />ccrtify thut lhc fcdcral rcgulations rcgarding asbcstos rcmval arc not applicahlc to this prcjcrt. <br />1\ mify ttl I hsvc rcad lhis applicrlion and ststc thrt thc stnvc informtion is corrcd. I agrc to smply with all Cityand County <br />o.dinaEcs und Stalc kws rchting to building conslruclion. and hcrcby authoria rctrcrcntatives ofthis City ard Countyto ent6 uJrn thc <br />above mcnlioncd propcrty for inspclion <br />/$pti"rnt or Agent <br />\ermitee <br />name c- <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf loor <br />Building Sewer <br />ArealStorm Drain <br />I nterceptor/ CIarif 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 lDrain Line <br />Main Drain/Pool Pipinq <br />Fil! Line/Back Flow <br />Pool Heaterlcas Line <br />Miscellaneous t <br />Gas Service <br />Water Service <br />Lawn Sprinkler I <br />Sanitary SewerlCao lz Ir tt )ftntrt v+ry <br />Back FIow Device <br />Rough Plumbins <br />Fina! Gas Test <br />Meter Release t,^A <br />FINAL a I P*\n71 -L_k5:) <br />Notes, Remarks , Etc fl <br />I <br />).. <br />Ir <br />/ <br />I <br />F..^-^ <br />Applicanl: <br />crass: G-t-\*.wl):rtt: <br />L)ale: <br />{ <br />\A +"1 '\-,'o