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PLUMBING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS 0WNER BUII,DER DEI,CARATION <br />I hcrchy ullirrn undcr pcnalry of pcrjury rhar I am cxctrrpl fft)m lhc Grilrack)rs' [-i<rnse hw lirr thc followirrg E*", tSi,rX tt-s <br />Bu\iIcss and Prolcssion Codc): Any City ol (lrunty shich rcquires a ;rrmil lo onstruct. ilher, imptorc. dcmlish or rcFEir any <br />structurc. Prior lo ils issuancc. llso rcquircs lhc npplicant for such [Ennil lo l'ilc a si8ncd slatclrcnl lhiil hc or shc is liccnsed pursrunl <br />b thc prolisions of tlrc Contrilckrr's Liccnscd law (Chnptcr 9. ConrrEncin8 with Sstion 7Ux) of Diviskrn J of thc Busircss and <br />Pmfcssions Codc) or lhat hc or shc is cxcmpt thcrcfrom rnd thc hd$is lilr lhe trllcgcd crcmplion. Any viohti{)n ofSsttrn 7031.5 by any <br />applicsnl lbr a pcnnil suhjsl$ lhc ilpplicanl h a civil pcnahy (,f not n{)rc thrn fivc hund.cd dollilrs ($5(x)). <br />_1.ts owncrofthcpmFrcny.orDycnrpkryeswilhwagcsrthcirvrlcconrpcnsalion.willdothcworkudlhcslnrlurcisnot <br />inlcn<lcxl oroffcrcdforslc(SN.?044.BusincssandProfcssiorsCfrlc:'lhcC{nlmclor'sLiccnshwd(tcsnolapplyloanownctof <br />thcpn)[Eny whohuildsorirll,rowslhcG)n.aildwhodessuchso*hitrr\clforhcrsclforlhroughhisorhcrowncmployccs. <br />f()vklcd that such improrcnEnts arc not irilcillcd or olIcrcd for salc. lf. hrwcvcr. thc huilding or impmtcrrcnl ir skl wilhir onc )car <br />ol cotrDldion. thc Owncr Buiklcr will halr lhc hurdcn ofproving thilt hc or shc dil ml huikl or in{rrolc lhc pmlrrly for lhc purtns of <br />slcl. <br />_1. as owner of the proFrerty. am cxclusively contracting with licenscd conlractors lo construct the pmjc.ct (Sec. 7W. Business <br />and Profession Code: Thc Contractor's Licensc Law does not apply lo an owner of property who huilds or improves thereon. <br />and who contracts for such proFcts with a Contracto(s) licenscd pursuant to the Contractor's License [aw). <br />-latltcxc!llptundcrScclion-.B.&P.C.ltlrlhisrcastrn. <br />I )ulr: ( )rr ltt'r: <br />WORKERS' COMPFNSATION <br />DF'CLARATION <br />I hcrcby affirnr undcr Fnalty of Jrcrjury onc of lhc frrllowing dcclarations: <br />_l huve and will maintain a Certificatc of Conscnt to Sclf-lnsurc for u'orkcrs' conrFrcnsation. as pflrvidcd for by Scction -37fi) of the <br />l:txrr Codc. for thc lrcrformancc of thc work for which thc lrcrrnit is issucd. <br />_lhavcandwill maintainworkcrs'conrpensationinsurancc.as rcquircdbyScction3T00ofthcLaborClodc.forthelrcrformanceof <br />thc work frlr which this pcrnrit is issucd. My workcrs' conrpcnsation insurance carricr and policy nunlbcr &re: <br />Policy Nurnbcr: Expircs: <br />-l <br />ccrtify that in thc prfornrancc of thc work for which this pcrrnit is issucd. I shall not cmploy any 1rcrson in any manner <br />so ns to heconrc suhjcct to the workcrs' conrJrcnsation laws of Califrrrnia. ancl agrcc lhal if I should bcconr subjcct lo thc <br />workcrs' comJrcnsation provisions of .Scction 37U) of thc l-.atnr Codc. I shall. forthwith cornply with ttxrs'e provisions.. <br />WARNING: Failure to secure workcrs' comyrcnsation covcragc is unlawful. and shall subject an cmploycr lo criminal penalties and <br />civil fines up to one hundred thousand dollars ($100.00t1). in addition lo the cost of compensation. damagcs as providcd for thc <br />Scclion 3076 of the Latnr Codc. intercst and Bttorncy's fees. <br />l):rlt': ,\;rplic:rrrl: <br />LICENSED C()N'I'RAC'TOR . <br />DECLARA'I'ION <br />I hcrchy alfirm undcr Jrcnalty of pcrjury that I anr lic',cnscd undcr prrvision of Chaptcr 9 (comrncncing u'ith Scclkrn 7fin) of Division .3 <br />of thc Busincss and Profcssions Clodc. arxl nry liccnsc is in full forcc antl cfl'cct. <br />Licensc Class: Liccnsc Numbcr: <br />I)nte: <br />W <br />I hercby sffrm undcr pemlty of lErjury thsl ttm is I @ritruction hndirS sgercy for thc pcrfomre of thc wk fot vhich this Fmit is <br />isswd (SE. 3097, Civ. C.). <br />Lcnder's Namc: <br />knder's Addrcss: <br />APPLICANT DECI ARATION <br />I hcrchy allinn urrtlcr pcnalty of pcrjury onc of thc ltlllowing dcclarltions: <br />I)crrxrlitiotr Pcrnrits-Asbcstos Notiflicalion l:cclcral Rcgulations ('titlc 40. l'lrt6) <br />-Rcquircd <br />Lctter of Nolificaliorr <br />| <br />-l <br />certify thst the fedcml ESuhlio!! rguding asbeslos rcmEl re ml rpplbsbh ro this pmirr. <br />I| <br />-l <br />cmify that I havc Erd thk spplhrtion otd ststc rhat rhc sborc infomtion ir cqrEt. I sgE ao otrply wilh lll City and Couoty ' <br />I ordimrcs sid Ststc LrB EhrlrB to buiHing sntrwliotr rod hcEby autlDrize EprcstsiiG of ahis Cily lrd Crunty lo nl6 upon 0r <br />I sborc rcntbrcd popcny for impcctbn purposs. <br />Apgrlicnnl or Agcnl Signalure:J.- <br />I <br />Permitee nnnre (print):__ _ <br />UNDER GHOUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf loor <br />Buildinq Sewer <br />ArealStorm Drain <br />I nterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rouoh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />l\Iain Drain/Pool Pipinq <br />Fill Line/Back Flow <br />Pool Heaterlcas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary SewerlC.ap <br />Back Flow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release <br />FINAL <br />Notes, Remarks, Etc. <br />,,