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PLUMBING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCANATION <br />I hcrcby affrm undcr Jrcmlty of pcrjury that I m cxempt frcm th€ Contrrctom' Liens lrw for the following rcaon (Sc.70.11.5 <br />Busincss and Pmfcssion Codc): Any City or County whhh rcquircs a Jrmit to onstruct. alte. inprorc. dcmlish or rc;nir any <br />struclre. prbr to ils issusre, dm rcAuires th€ spplicant for such pcmil k, filc 8 sigrcd ststcmnt thar he or slE is liensd pusoil <br />lo thc pmvisions of thc ContEctd's Li(tned lrw (Chapter 9. Comreming with Sslion 70il) of Division 3 of thc Busircss and <br />Pofessions Codc) or that hc m she is excmpt thcrcfrom and thc basis for thc slhgcd cxcn{rtbn. Any violstion of Setbn 7031.5 by rny <br />applicanl for r tEmit subjets thc rpplicul to a civil pcnalty of mt mrc than fire hundrcd dollils ($50O). <br />-1. <br />as owrrcr of thc propcrly. or my emplo)rces with wagcs as thcir solc conqrcnsation. willdo the work and thc structurc ls nol <br />intcndcd or offcred for sale (Sec.7M4. Business and Profcssions Code: The Conlractor's Liccnse [-aw does not apply to an owncr of <br />the proSrcrty who builds or improves thermn. and who docs such work himsclf or hcrsclf or lhrough his or her own employccs. <br />providcd lhsl such improvenrnls are not intended or offcrcd for salc. lf. howevcr. the huilding or improvenrnt is sold within one )car <br />of complction. thc Owner Buildcr will have the bl.rdcn of proving lhat hc or she did not build or inrprove the propo'ly ftrr the pur;nsc of <br />sah). <br />-1. <br />as owncr of thc property. am exclusively contracting with liccnscd conlraclors lo construct lhe projcct (Sec. 7M4. Business <br />and Profcssion Codc: Thc Contraclor's License Law does not apply to an owncr of property who builds or improves thercon. <br />and who conlracls for such projects with a Contractor(s) liccnsed pursuant to thc Conlraclor's License Law). <br />-l <br />am exempt undcr Scction_. B. & P.C. for lhis rcason. <br />Dete:_( )rr ner <br />WORKERS' CODIPFNS ATTON <br />DECLAITATION <br />I hereby affirm undcr Jrcnalty of pcrjury one of thc following declarations: <br />-l <br />have and will mainlain a Certificate of Consent to Self-lnsurc for workcrs' compcnsation. as pmvidcd for by Section 37fi) of the <br />Labor Codc. for thc pcrformtnce of thc work for which the pcrmit ls issucd. <br />-l <br />havc and will maintain workers'comFrcnsation insurancc. as required by Scction.iTfi) of thc Labor Code. for thc Jrcrformancc of <br />thc work lirr u'hich this ;rcrrrrit is issucd. My workcrs' cornpcnsation irrsurlncc carricr ard prlicy nurnbcr arc: <br />\ Svqes{ Prcnier lrtsvrcnrc eCurricr: <br />Policy ol-ol -2v70 <br />-l <br />ccrtity thal in thc pcrformance of the work for which this pcrnrit is issuctl. I shull not crnploy any pcrson in any mrnncr <br />so as to hccome subjcct lo thc workcrs' compensati<ln laws of California. and agrcc lhat if I should bcconrc suhjc"ct to thc <br />w<lrkcrs' compcnsation provisions of Section 3700 of thc t ahr Code. I shall. t'oflhwith conrply with those provisions.. <br />WARNIN(l: Failurc to sccurc workers' comJrcnsation coveragc is unluwlul. and shall subiccl an crnploycr to crinrinal Jrrraltics and <br />civil fincs up to one hundrcd thousand dollars in addition to lhc co$ of compensation. damages as provided for thc <br />Scction 3076 of thc l-atnr Ccxlc. interest and <br />,r.", 4- L'l'l? <br />DECII\RATION <br />I hereby affirm under pnalty of pcrjury that I am licensed under provision of Chapter 9 (comnrcncing with Sc.ction 7m0) of Division 3 <br />of the Business and Profcssions Code. and my lhense Ls in full force and effect. <br />Liccnsc Nurnhcr: <br />W <br />I hmby alfrm undcr JEmlty of Frjury that thm is s snstruction hndirg rgcncy for thc pcrfomcc of the work for which this Frmit [i <br />issucd (SE. 3(x)7, Civ. C.). <br />Lrndcr's Nrlnc: <br />lrndcr's Addrcss: <br />APPLICATTT DF'CLARATION <br />I Mryaffrmunder penalty of perjury one of the following declarations: <br />Dcmolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) <br />-Requ <br />ircd lrt tcr of Notifrcation <br />-l <br />ccrtify that lhe fedcral regulations rcgarding asbcstos removalarc nol applicablc to this projcct. <br />with all City and County <br />and County to cntcr ugrn thc <br />alxrvc rncnlioncd propcrty l'or <br />Aplllicanl or Agtnl <br />I)rrnrilct' nnnrr 5 <br />J)olo.//-Z?-rq <br />UNDER GROUND <br />Waste & Vent <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 Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary SewerlCap <br />Back FIow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release <br />FINAL /lz-/ar //c%,,r <br />Notes, Remarks, Etc. <br />-l <br />7 <br />l)ate://-2? -/c7