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PLUM BING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER EUILI'ER DELCARATION <br />I hcrcby smrm under pemlty of pcrjury lhat I m crsmpi from the Conlrelm' Licens l.lw for lhe following msn (54.7031.5 <br />Business rnd Pmfession Code): Any City or County which rcquircs I Fmill to sNtruct. rlt6. imprcre. demlish or repair any <br />structure. prhr to its issuance. also requires the spplicsnt for such Jrrmit Io filc a signed slalemnt thst hc or shc is licnsd ptrunl <br />to thc pmvisionr of tlrc Conlmctor's Liccn$d kw (Chqrter 9. Comncing wilh S$tion 7(m of Division 3 of lhc Busiress md <br />Prcfessions Codc) or lhst he or sh€ is crempt tffim and thc besis for thc rlhg€d excmptk o, Any violstion of S€rirn 7031.5 by rny <br />applicant for ! ,rcmit subjsts thc spplicsnt to 8 civil lEmlty of ml mrc lhsn five hundrcd dollus ($5fi)). <br />_l.as ou'ncrol'lhcpropcny.orrtrycml)loyccswithrvagcststhcirsolccornl)cnsiltion.s'illdollrcu'orkilndthcslnr-lurcisnot <br />intcntlcd ()r ()flcrc(l frlr salc (.Scc.7(114. l]usincss and Prolbssions Cloclc: 'l'hc Cortlractor's Liccnsc l.itrv <locs not itpply lo itn owncr of <br />thcpropcrly u'hohuildsorinU)rovcsthcrcon.andwhorl<rcssuchwrlrkhirnsclforhcrsclforthrouglthisorltcrowttctnployccs. <br />of'corrplcliotr.llrc Ou'ncr Buildcr u'ill havc thc burdcn ol'pror,ing lhat hc or shc clitl rxrt build or irrtJrrovc lhc propcrly for lhc purprsco[ <br />srlc). <br />_1. as owncr of thc proprty. am cxclusively contracting u'ith licensed cclntractors to construct lhc pmjcct (Sec. 7W. Business <br />and Pnotbssion Codc: The Contraclor's License Law docs not apply lo an owner of proSrcrty who builds or improvcs thereon. <br />and who conlracls for such projccls with a Contractor(s) licensed pursusnl lo the Contractor's Liccnse Law). <br />-IantcxcmplundcrSection-.B'&P.C.forthisrcason'Owner:___ <br />WORKF'ITS' COM PENSATION <br />DECLAR.ATION <br />I hereby uffirm under pcnalty of pcrjury one of thc following dcclarations: <br />-l <br />have arxt will maintain a Certificatc of Consent to Sclf-lnsurc for workcrs' compcnsation. as providcd for by Scction 3700 of the <br />latror Codc. for the Jrcrfonnance of thc work for which thc grrmit is issued. <br />-l <br />havc and u,ill mainlain .3700 of the Labor Code. for the pcrformance of <br />thc rvork lhis and Jxrlicy rturnbcr ire: <br />Policy ?63 6 /O-/-ZQ <br />_l ccrtify that in the yrcrforrnancc of thc work for which lhis;rcrmit is issued. I shall not employ any person in any manncr <br />so as to become subjcct to the workers' compensation laws of California. and agree that if I should bccomc subject to the <br />workers' compcnsation provisions of Seclion 3700 of the Labor Code. I shall. l'orlhwilh comply with thosc provisions.. <br />) <br />lVARNIN(]: I;ailurc l() sccurc \t,orkcrs'is unlawt'ul. and shall subjcct an cmploycr to criminal ,Lnahies and <br />addition lo thc cost of comlrcnsation. damages as providcd for thccivil fincs up to onc hundred thousand <br />Scction -1076 of thc l.irtnr Codc. intcrcst and <br />/- <br />I hcreby affirnr undcr Jrcnalty o[ prjury that I arn liccnscd Chaplcr 9 (comrrrcncing with Scction 7U)()) of Division 3 <br />of thc Business and Profcssions Code. and my licensc is in full force and cffe'ct. <br />) <br />Numher: <br />q6S) sfLicense <br />Dale:(/-fr.-t9 <br />CONSITITJCTION LENITNG AGENCI <br />I ltrcby alftrm urdcr Fnslry of pedury thst therc is s ansttrtbo lerding rgcmy for the perfomre of lhc mrk for whhh this pcrmil h <br />issucd (Ss. 3097. Civ. C.). <br />l-cndcr's Nantc: <br />lrndcr's Addrcss: <br />APPLICANT DECLARA'I'ION <br />I trcrehy allrrnr undcr pnalty of pcrjury onc of thc follos'ing dcclarations: <br />Dclrrolit iorr Pcnnits-Asbcstos Not illcal ion Fcdcral Rcgulat ions (Titlc 40. Part6 l <br />_Rc<lu irctl l-ct lcr of Notillcal iort <br />_l certify lhal thc fcdcral rcgulations regarding asbcslos rcnnvalare nol applicablc to this proict. <br />-l <br />certify thal I havc rcad this with all City and County <br />and County to cnter upon the <br />abovc rrrcntioncd propcrty tbr <br />Applicanl or Agent <br />(^)Pernritee n0nre 4 <br />orrr. I )-)2'17 <br />UNDER GROUND <br />Waste & Vent lt I t1 ltl DAmai Lkl'f - Aur*l Cce*tmrl { <br />Water-Under floor ur <br />Gas-Underf !oor <br />Building Sewer <br />ArealStorm Drain <br />! 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 />POOL/SPA <br />P-trap/Drain Line <br />Main Drain/Pool Pipinq <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewer/Cap <br />Back Flow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release I <br />FINAL lt nlPt maoe LfrIOI <br />Notes, Remarks, Etc.I f' <br />[hea,^ <br />€--3L