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PLUM BING-INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATTON I hcrchy offirm under pnalty of pcrjury lhal I am exempt fmm lhc Contractom' Licens llw for thc following ca$n (Ss.7031.5 Busincss snd Profcssion Code): Any Cily or County which rcquircs r pemit to construct. allci imprcvc. demlish or rcpair any slructurc. Irk r to ils issuarce. sls rcquircs lhe applicrnt for such ,Emit to Iile I sigred stalerent that he or slrc k licensd puKuant to lhc pDvisions of the Contractor's Lkensd kw (Chrptcr 9, Comrcing wilh Setion 7000 of Division 3 of the Busircss ed hofcssionsGrdc)orthathcorshciscxemptthcrcfrcmandthcbesisforthcallcgedcxcmption. Anyviofifiotrofsfftion703l.5byany spplicsnt for I lrcrmit subjccts thc applicanl to I civil pcnslly of not mrc ther five hundrcd dollus ($500). -1. as owner of the propcrty. or my employoes with wages as their solc comfrcnsation. will do the work and the structurc is not inlerxled or offercd for sale (Scr.7O44. Busincss and Professions Code: The Contractor's License l-aw does not apply to an owner of the propcrty who builds or improves thercrrn. and who does such work himself or herself or through his or her own employees. providcd that such improvcrrcnls anc nol interdcd or offered for salc. If. however. the buiHing or improvenrcnt is sold within one )rar of conrplction. the Orvner Buildcr will have the burden of proving thal he or she did not build or inqlrove thc property for the purpsc of sale). -1. as owrrcr of thc propcrty. am cxclusivcly contracting with liccnscd contractors to construct thc projc.ct (Sec. 7W. Busincss and hofcsskrn Codc: Thc Contractor's Licensc Law does not apply lo an owner of property who builds or improves thercon. and who contracts for such projccts with a Contracto(s) licenscd pursuant to the Contractor's License kw). for this 7 I hcrcby al'firnr undcr pcnalty of pcrjury of thc -l havc and will maintain a Certifrcale of Consent to Self-lnsure for workcrs' compensation. as provided for by Section 37fi) of the I-sbor Codc. for thc grcrformancc of thc work for which the pcrmit ls issued. -l havc and will maintain workcrs' compcnsalkrn insurance. as rcquircd hy .Section 37fi) of the labor Codc. for thc prcrformancc of thc work lbr which this;rcrnrit is issucxl. My workcrs' comlrcnsation insurancc carricr and plicy numbcr are: Policv Nu:ntrcr: Exnires: -l ccrtify thul in the Jrcrfnrnrancc of thc work for which this pcrmit is issucd. I shnll not cmploy any pcrson in any ranner so as to bcconrc subjcct to the workers' co:npcnsalion laws of California. and agrcc thal if I should bcconrc subjcct to thc workers' compcnsalion provisions of Scction 37fi) of thc Lahrr Codc. I shall. tbrthwith comply with thorc provisions.. WARNIN(i: Failurc lo sccurc workcrs'covcragc is unlawful. and shall subjcct an cmploycr lo criminal Jrcnaltics and civil lincs up lo onc hundrccl thousand dollnrs addition to lhe cost of compcnsation. damages as providcd for thc I hcrcby alfirrrr unrlcr pcnalty of'pcrjury that I arn provision of Chaptcr 9 (comrrrcncing with Section 7000) of Division 3 of lhe Busincss and Profcssiorts Code. and rny liccnsc is in full forcc and cft'cct. Licensc Date: Nurrthc'r: ('oltl r:rclrlr W I hcrcby affirm undcr pnalty of trcrjury lhal thcrc is s @nslructbn lcodirg agcrcy for thc lrcrfomrcc of thc uork for which this pcrmil is issucd (Src. .1097. Civ. C.). kndcr's Nanrc: Lcrder's Addrcss: APPLICANT DECI ARATION I hcreby affrnn undcr ;rcnalty of prjury orc of the following declarations: Dcmolition Permits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40. Pan6) -Rcquired lrttcr of ]lotification -l ccrtify that thc federalregulations regarding ashcstos renrovalarc not applicablc to lhis project. and slate lhat lhc atnve information is correct. I agrc= to comply with all City and County and hcrcby authorizc reprcscntatives of this City and County to entcr uJnn lhc IApplicant or Agent Permiteer@ il 71 UNDER GROUND Waste & Vent Water-Under floor Gas-Underf loor Buildinq Sewer ArealStorm Drain ! nterceptor/ CIarif ier TOP OUT Waste & Vent Water Pipinq Gas Pipinq Roof Drain Tub/Shower Test Rough Water Heater POOL/SPA P-trap/Drain Line Main Drain/Pool Pipinq Fill Line/Back Flow Poo! Heaterlcas Line Miscellaneous Gas Service Water Service Lawn Sprinkler Sanitary SewerlCap Back Flow Device Rough Plumbing Final Gas Test Meter Release I FINAL l"f tt !t4 Xf.,Z-tr+el \/4/>/ Notes, Remarks, Etc.\) \ \-' Carricr: :,:::-'w';"':rcrcsr /'zcrn f