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PLUMBING-INSPECTOR RECORD <br />APPROVALS DATE !D/SIG COMMENTS OWNER BUII,DF,R DEL(:ARATION <br />I heelry aflirm under psalty of pqjury lhal I an crempl from thc ('ontraclos' l-icose [i* for the follo$ing reen (Ss.?0.11.5 <br />Businss and Prof6sion Codc): Any City or County $'hich requirc a pmnil lo conslrucl. ahs. itnprovc &molish or rqair any <br />shrcture. pilor to its issuancc. also requirs the applicant for such Jnmit lo filc a signcd stalsnml th.t hc or shc is licosed pursuanl <br />to the Frovisions of thc Contraclor's Licqscd l,arv (('hapter 9. Commencing Nith Sfition ?000 of Division I of lhe Busincss and <br />l,rofcsions Code) or that he or she is cxmpt thtrfrom 8nd thc tnsis for lhe alleg.d erqnplion. Any riolslion of Sclion 7031 .5 by any <br />applicanl for a pemlit subjets the epplicant to a civil p€nalty of not more than fi\,e hundred dollas ($500). <br />, l. as 0\116 of thc Jro1rrty. or my cmptoym s'ith wags re their $le comfmsation. lvill do the $ork ild thc stnKlue is mt <br />irrtmdcd orolfsedfoislc1Sa.7044.BusinssandProfsionsCodcr'lheContrs.lor'sI.icflsLaNdo6nolapplytoano\\rdof <br />thc pR)peny rvho buikls or inprovs fhffirn. ud lv[k) do6 such $nrk himsclf or herslf or thrcu8h his or ho orvn cmploycc. <br />prot i lcd that such hnpovqrents N not intodql or ollbed for $le. lf. ho*46. the b{ilding or imprcvemcnt is skl wilhin one }eo <br />ofcomplction. the Owm lluilds wilt havc thc hrrdm of p6,ing tha he or she did not boitd or imtmrc ftc pmperty for thc purposof <br />sle). <br />, l. m otvne ofthc pro[Eiy. an crclusivcly contracting $'ilh licoscd contracloE lo conslrucl lhe prejccl (S(. 7G14. BNin* <br />anll'nhsirnCotle:'l-hcContractor'sLicenscl-arvdocnotappl]'/loano\r'nsofpropcrtylrhobuildsorimprer'csthsrcn' <br />and w.ho contracts for such pojets rvith a Conlraclo(s) licmsed puBuanl lo lhc Contraclor's Licose La\r). <br />-,1 arn exempt unds Setion.-- - - -. --. B. & P.('. for this re6on. <br />l)nle: Ou ner: <br />\\'o RK ERS' ('( )ll I'l,.Ns,\'l'l()N <br />Dli('l,,tll,\ l'l()N <br />I Icrc[t nl-fir'ttt r.ln(lcr l]ctlah\'()f'ptlitlr]'()llc ()l lhc l6llo5 ilg tlcclittitli(\tls: <br />_l have a1d rvill maintain a Certificate of Consent to Self-lnsure for rvorkers' compensalion, as provided for by Se'ction ^1700 of the <br />Labor Code. for the perfonnance of the work for u'hich the perrrrit is issued. <br />_ I have and g,ill maintain workers' compensation insurance. as required by Section -1700 of the Labor Code. for the performance of <br />the work for rvhich this perrnit is issued. My rvorkcts' cornpensation insurance calrier and plicy numkr are: <br />Policv Number:l rpir cs <br />_l certify that in the performance of the work for rvhich this perrnit is issued. I shall not employ any person in any manner <br />so as to become subjeci ro the work€rs' compalsation lau's of California. and agree that if I should become subject to the <br />\\,orkers' comperuaiion provisions of Section -1700 of the Labor Code. I shall. forths'ith comply with thosc provisions.. <br />WARNING: Failure to secure workers' comFrensation coverage is unlarvful. and shall subject an to crirninal penalties and <br />civil l'rnes up to one hundred thousand dollars ($100.000). in as provided for the <br />Section 1076 of the l.abor Code. interest and altorney's <br />I hereby affirm under penahy of perjury that I am licensed of Chapter 9 (commencing with Section 7000) of Division -1 <br />of the Business and Professions Code. and my license is in full force and effect. <br />License Class:-License <br />I)itIt' <br />CONS'I'RUC]1ON I,ENDING AGENCY <br />I hachy aflinn under FEnalty ofpsjury lhat th* i" . <br />"onrt..tiun <br />Lndin! agqcy for thc psftrnnance ofthe rvork for rvhich dris Jurnit is <br />issued (Sc. -1097. ('i\'. C.). <br />I.ender's Address: <br />APPLICANT DECLARATION <br />I hoEby affinn undcr penalty of perjury one of the follorving declarat ions: <br />Demolition Permits-Asbestos Notification Federal Regulations ('l'itle 40. Part6) <br />-_-Required Letter of Notilication <br />_l cerri$, that the ferjeral regulations rcgarding asbestos removal are not applicable to this projeo. <br />- <br />I cerrify that I have read this application and state that the above is correct. I agree to comply with all City and County <br />theordinances and State Las's relating to building of this City and County to enter upon <br />above mentioned propefly for inspection <br />Applicnnt or Agent <br />l'crlttilt'c <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />I nterceptor/ Cla rifier <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 HeaterlGas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitarv Sewer/Cap <br />Back Flow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release ^ll fln o {A <br />FINAL l;/IK In <br />Dete:_ <br />) <br />( <br />J <br />ft€,z <br />V,lNtll,t&l4w <br />Notes, Remarks, Etc.