30140741 - Permit (2) - Laserfiche WebLink

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PLUM BING.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OTVNT.:R BUILDDR DDLCARA'ilON I herchy aflirnr under penalty of perjury rhfl I am exempr linm the ('ontractors' License l-aw for the folbwing rc.$n (s6.703 L5 r Business an! Profession Code): Any City or Couily which requires a pemil to snslruct, .hs, impft)\t. demlish or repair any slructurc. prior to its issuarce, also requircs thc applicant for such Jrcnnit to filc a signed shterEnl lhfl hc (lr shc is licensed luNanl to lhe pmvisions of rhe Contractor's Licensed Lau' (Chapter 9, Commencing silh Section 7fi)0 of Division I of thc Business and Pnrfcssions Code) or lhat hc or she is exempr rherefrom and rhc basis for thc allcged cxemption. Any violation of ScIkrn 703 1.5 by any ' applicant for a pemit subjects the applicant to a civil pcm[yofmt morc than live hundrd dollars (S500). t? $ u" no.n.. nf Ih. pmJErty. or my ernployces with wages as their slle smpenglion, sill do lhc work aill the stmclurc is ml intcrxld or oflercd fur mlc (Sa.7M4, Business and Prrfessions Code: 'l he Contractor's Liccnrc Llw ckrcs mt apply to rn o$ner of lhepmff,rly u'hobuildsorimpmvslhercn,arxlwh)dosschworkhinselforherselforthmughhisorhcrownemployecs, Jrrevided that such inrpmwnts arc mt intenddl or off.rcd ftrr mle. Il, h)wevq, the buiHin8 or impmlemnl k sH within one ]tar of strpletion, lhc Owner Builder will havc the hurlen olpmving thtrt hc or shc did mt huild or impmtr the pmpcrty for thc puryneof sle). _1, as owner of the pmperty, an exclusivcly conlmcling with licensed conlraclom to construcl lhc pmjst (Src. 7(X4. Businesq orxl PmEsirn Code: 'l'he Contractor's l-icense Lsw doer not apply to an owner ofpmpeny who huilds or imprcver lhereon, and s'ho snlmcls for such pmjftls wilh a Conlmclo(s) licensed pursunt to the Contractor's Liccnse ljw). -l am B. & P.C. lbr this reason. Owner: WOU('R-' COMPENSAT DECLARATTON I hereby amrm under penalty of perjury one of the ftrlkru'ing declarations:/ V. lhavearxlwill maintainaCertificateofConselrt to Self-lnsure ft)rworkers'contpensalion, as p()vi(led forhySectionlT00ofthe Latxrr Code, for the perfornrance of the \r'ork fi,)r which the pernrit i.s issued. _l have and will maintain workers' conlpensation insurance, as required by Section 3700 of the l-abor Code, for the perft)rmance of the work lirr u'hich tflis permit is Itlo LcLl issued. My workers' compensation insurance carrier and plicy number are: A l'olicy c t1 _l certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers'compensation laws of California, and agree that if I slrould become sub.lect to thc workers' cornpensation pro!'isions of Section 3700 of the Latnr Code, I shall. forthwith comply with tlnse prot'isions.. WARNING: l;ailure civil fines up lo one to secure workers' compensstion coverage is unlawful. and shall zubict an ernployer to crirninal pennlties and hundred tlrousand dollars (S100,0m), in addition to the of compensation. damages as provided for the Seclion -J076 interest and attorney's fees. 3 v ^JI ICENSED C()N'I'RAC'I'()R IIECLAR.\'I'ION I lrercby nf firrn under penalty of perjury thal I arn licenscrl uncler provision of Chapter t) (commencing rvith Section 7000) of Division 3 of the llusiness and Prolbssions Code, ancl rny license is in full ftrrce and effect. License Date: Number: (lontrnctor: W I hccby aflirm urda lEmlty of ptrjury that ttm ii 8 onlrucrion lending ogcrcy for thc pcfomre of thc rcrk fo, which thir pcrmil i3 ir$cd (56. 3097, Civ. C.). Lender's Name: Lender's Address: APPLICAN't DECLARA'I'ION I trrebyalfinnuncler penalty of perjury <lne of the fullowing cleclarations: Denrolit ion Permits-Ashestos Noti fi cation l;ederal Regulal ions ('l'itle 40, Part6) -Requirerl Letter of Notification _l certifythat the federalregulations regarding ashcstos rernovalare not applicable to this pmject. -l certify lhal I have read this application and state that the atnve information is correct. I agree to comply with all City and County ordinances and State Laws relating to building and hereby autlnrize representatives of this City and County to enter uFlon the ahove nrenlioned properly fur inspection il4luAppllcarrt or Agent t/I'ernritee nRnrG / gr.tO L AS Date: UNDER GROUND Waste & Vent Water-Under floor Gas-Underfloor Building Sewer Area/Storm Drain I nterceptor/ Clarifie r TOP OUT Waste & Vent Water Piping Gas Pipinq Roof Drain Tub/Shower Test Rough Water Heater POOL/SPA P-trap/Drain Line Main Drain/Pool Pipins Fill Line/Back FIow Pool Heater/Gas Line Miscellaneous Gas Service Water Service Lawn Sprinkler Sanitary Sewer/Cap Back Flow Device Rough Plumbing Final Gas Test Meter Release // FINAL 5/*r//t TtXl(zb ) Notes, Remarks, Etc.ll \rrr-