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PLUM BING.INSPECTOR RECORD <br />APPROVALS DATE !D/S!G COMMENTS OWNER BT'ILDER DELCARATION <br />I lrcrcby afftrm unds pcnslty of Frjury rhar I m excrpt fiom thc CoilrctoD' Liens kw for the following rc8sn (Se.703la <br />Busincss ard Prcfcssion Codc): Any City or County whkh rcquircs s Imit to snstruct, dte, inprcrc, &mlish or rpair any <br />structm. pdor to its, ieruancc. dso rcquircs the applicmt for such pcmit to file a signed statcmnt thst lE or rhc k licnsed puunt <br />lo the prcvisions of thc Confrctor's Liccnsd [:w (Chapttr 9, Comrercing with Sstion 7000 of Division 3 of thc Business rnd <br />Pmfcssions Codc) or thrt hc q she is cxcmpl thercfrom aod thc b&sis for the rllegcd cxcrl,,thn. Any violstion of Scctbn 703 1.5 by any <br />spt licant for r pcmit subjixts lhe spplic8nt to 8 civil pcmlty of mt mrc lhsn five hundrcd dollur ($500). <br />!( ". o**, of thu Fo1rrty, tr my empk les with wrges &s thcir $lc ompcosation. will do tlE wGk ud llE ilnrrw k mt <br />intendcd r olfercd for sle (Se.7044. Busircss ud Prcfcsions Codc: Thc Contrac{ff's Lkrns hw does not spply lo u owrer of <br />thc tmtrcny who buildr or itr{mrcs thcmn. ard who des ffh wrk himrelf or hcrslf or lhmugh his or hcr own cmployes. <br />providcd that such impmrcmnts re rct htqdcd or ofu for sle. lf. howrei the buildinS or impmwmnl is sh within onc ]qr <br />of @tr{rl:tbn, the Owrer Builder sill haw ilE burdcn of prcving th[t ]E or shc dit mt boild tr itrproE tlE pmFry for thc purpos of <br />mls). <br />_1. as owner of the proFrcrty. am exclusively contrBcting with liccnscd conlraclors lo construct thc projcct (Scc. 704/. Business <br />atd Profcssbn Codc: Thc Contractor's License LBw docs not apply lo an owner of propcrty who builds or improvcs thereon. <br />and who contracls for such projccts wilh a Contractor(s) licenscd pursuunt to the Contraclor's Licensc l-aw). <br />-l <br />artt urrdcr B.P.C. ltrr this <br />Dale:2 4 <br />I hcrcby alfirrn undcr Jrcnahy of pcrjury onc of thc <br />l-alxrr Crxlc. Ibr thc pcrfrrrrnancc oI thc work ltrr which lhc pcrrttit is issucd. <br />-l <br />have and will maintain workcrs' comlrnsation insurance. as rcquircd by Scc'tion 37fi) of lhc [:bor Codc. for the ;rcrformarrcc of <br />lhc work for which this pcrmit is issued. My workcrs' compcnsation insurancc carricr and plicy numhr are: <br />that in lhe pcrfornrance of thc work for which this pcrmit is issucd. I shall not employ any person in any manrrcr <br />should bccorne subject to lhe rso as lo hccomc subjccl to thc workcrs'comF,cnsation laws of California. and agrce thal if I <br />workcrs' compcnsation provisions of Section 37fi) of thc l-abor Code. I shall. forthwith comply with those provisions.. <br />WARNING: Failurc to s:ccurc workcrs' conrpcnsation coverage is unlawful. and shall aln arxl <br />civil lincs up to onc hundrcd lhousand dollars ($1fi).fiX)). in lo lhc cosl of thc <br />Sccliolr .1076 Codc. inlerest and attrlrncy's <br />I hcrchy affirm undcr pcnalty of pcrjury that I ant Chaptcr 9 (commcncing with Scction 7m0) of Division 3 <br />ol' thc Busincss and Professions Codc, and nry is in full lirrcc ancl clfccl. <br />Licensc Class: License Numbcr: <br />l):rlr ('onlritt'lrlr <br />W <br />I hcrcby affrm undcr pcmlty of lErjury thrt thse is s @nstrctbo bnding agercy for the frcrformre of the wrk for which this Imil is <br />issucd (Se. 3097. Civ. C.). <br />kndcr's Namc: <br />[.cndcr's Address: <br />APPI ICANT NT'CLARATION <br />I hcreby sffirm under penalty of perjury one of the following declarations: <br />Demolition Permits-Astrstos Notification Federal Regulations (Title 40. Part6) <br />-Rcqu <br />ired [rtter of Notificatbn <br />-l <br />ccrtify that lhc fcdcralrcgulations rcgarding asbcstos rcmovalarc not applicable to this proicl. <br />_l ccrtity that I havc rcad this application and statc that thc atnvc information is concct. I agrcc to comply with all City and County <br />ordinanccs and State laws rclaling lo <br />atxlvc mcntioned properly for insJrcction <br />r\llplicant ()r /\gent <br />Pernrilee nanre <br />hercby authorizc representatives of this City and County to enter upon thc <br />UNDER GROUND <br />Waste & Vent / /-)).rq /ZC2l 7 <br />Water-Under floor <br />Gas-Underf loor <br />Buildinq Sewer <br />ArealStorm Drain <br />I nterceptor/ CIarif ier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />Main Drain/Pool Pipinq <br />Fill Line/Back Flow <br />Pool Heaterlcas 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 />F!NAL / l "€,1'1 trc%r,I <br />Notes, Remarks, Etc. <br />0wner: <br />Carrier:- <br />Itt