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I hereby affrrm under penalty of perjury that I am exempt from the Contractors' License Law for the following reason (Sec.703 <br />in addition to cost <br />t.5 <br />Buioe srd Prcfe:ion Codc): Any City or Counly which rcquiB a pqrnit to omtruct. dl6, iEprovc daolirh or rtpah uy <br />smctEc. Fhr to fu irsure, ds rcquis thc qptimt for sch pamh to filc a rigrrcd ltd@at lhd h. or lhc b licascd prsu <br />to thc prcvisioN of thc Contrrctq'3 Liqscd Lrw (Chrpt6 9. Commcing with Setiotr ?000 of Division 3 of thc Buins md <br />PmfcssiomCo&)uth8thcorlhcisqmplthEr&omedthcbcsbforthcalcgodamption. AayviolntionofsctbnT03l.5byey <br />8pplicutfor6p6mit$Uictsthc applicmttoacivilpcolhyofnolmrcthmlivchufudollan(t500). <br />-1, <br />a owq of thc popaty. or my mployc with w8g6 a thcir rlc compcnsaioq wiu do tlE wod( Etd tlE leudre i mt <br />intodcd or ofraod fu sk (Sc.7044. BBiK md Pr,ofeiom Codc: Thc Corrrstq's Lirffi kw doa not pply to u ow of <br />thc popqty who buildr or imFore tlson sd who dq reh rclt himsclf or ls*lf or thrcugh his or hc om mploye, <br />provid thrt such imprcmts rc mt trtad.d or oftrcd 6r sb. If, how. thc buildiry or inqrcvunca b sld wilhin G )6 <br />of onplabu thc orrm Builda will haw th hrdo of povirg ilra trc or rhc dil mt hdld or iqrorc fic pop.ny br tlE Frpcc of <br />salc). <br />_1. B ow of thc prcpcty. m acluivcly oilr8ring with lics!€d @ntrac{oB to onirucl th€ pojcr (Se. 7044, htsitB <br />aod Protsim Codc: Thc Contraclor's Licmc Law dos not apply to m oMa of prcpcty who builds or imprcv6 th6@!, <br />md who ontracls for swh Fojds with a Conrrc{o(s) licancd puruan to thc Conbaclot'! LLrffi Lry). <br />.-l arn exempt under Section-. B. & <br />Date:lL^ lL(^20 <br />I hcreby alTirm undcr pcnalty of pcrjury one of the following <br />-l <br />have and will maintain a Certificate of Consent to Sclf-lnsure for workcrs' compcnsation, as providod for by Section 3700 of the <br />Labor Code for the performance of the work for which the perrnit is issued. <br />-l <br />have and will maintain workenr' compensation insurance, as requhed by Section 3700 of thc Labor Code, for the pcrformance of <br />thc work for which this permit is issued My workcrs' compensdion insurancc carrier md policy numk rc: <br />Policy Number: Expires: <br />_l certi& that in the performance of thc work for which this permit is issued. I shall not ernploy any person in any manner <br />so as to become subject to the workers'compensation laws of California. and agree that if I should become subject to the <br />workcrs' comperuation provisions of Sedion 3700 of the labor Code. I shall. forthwith comply with those provisions.. <br />WARNING: Failure to secure workers' cornpensation coverage is unlawful. and shall subject an onployer to criminal penaltics <br />as providd for <br />anc <br />rhicivil fines up to one hundred thousand dollars ($100.000), <br />Section 3076 of the l-abor Code, interest and attorney's fees. <br />I hereby affirm under penalty of perjury that I am licensed provision of Chaptcr 9 (commcncing with Section 7000) of Division 3 <br />of the Business and Professions Code, and my license is in full forcc and effcct. <br />f)olp'Conlraclor: <br />W <br />t h@by affum undq poaky of pcjury that thoc is 8 construction lcnding agocy for thc po'fomcc of thc wrk for which this Fmil b <br />i$ucd (Se. 3097, Civ. C.). <br />lands's Nmc: <br />- <br />License Class: License Number: <br />knder's Address: <br />A PPLICANT DEC LIIRATION <br />I herEby affirm und€r poalty of pcrjury one of thc following dcclarations: <br />Dernolition Pcrmits-Asbcstos Notification Federal Rcgulations (Title 40, P8rt6) <br />-Requhed <br />l-etter of Notification <br />-l <br />ccrti$, that the federal regulations regarding asbestos removal are not applicable to this project. <br />ccrtiry that I have read this application and state that the above <br />and State Laws relating to building construclion. and <br />above mentioned property for inspection purposes. <br />with all City and County <br />and County to enter upon the <br />/2^/A/- 2o <br />Date: axApplicant or Agent <br />Permitcc name <br />APPROVALS DATE ID/SIG.COMMENTS <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Building Sewer <br />ArealStorm Drain <br />I nterceptor/ CIa rifier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Piping <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 SewerlCap <br />Back Flow Device <br />Rough Plumbing <br />A,Final Gas Test <br />Meter Release /A l <br />FINAL )YIt+\t <br />Rema Etc.I <br />-D <br />PLUM BING.INSPEGTOR RECORD <br />Owner: <br />Carrier: <br />,",u. '(2^/Y'2o <br />=-r <br />c <br />q_a L.?\ <br />7,- l1-)9