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PLUMBING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER ETM.DER DELCARATION <br />I hercby affrm undcr ]rcnally of pcrjury thst I m cxcmpt ftom the Crntrscton' Lkc[s hu for the following rcsrcn (Sec.7031.5 <br />Busincss rnd Pmfessirn Code): Any City or County whbh requircr s pemit to @nstruct. rlt6. itrprcE,cdcmlish'or rtpair any <br />strucluB ]rhr lo its issumc. alrc rcquiEs the applbut for such Jrmit to filc s rigrcd slalcrcnl thrl hc or drc k liccnsd pumsd <br />to thc prcvisk ns of thc Conlrrctor's Liccnred [rw (Chapter 9. Collmrcing with Setion 7000 of Divbion 3 of thc Busiress and <br />PrcfcssionsCodc)orthstlrcorsheiscxcmpttlHefromaidthebosisforthcrllcgcdexemption, AryviolstionofsetbnT03l.5bysny <br />applicant for 8 Fmit subjrrts the applicsnt to r civil pcn.lty of nol mrc thm fivc hundrcd dollEs (S50O). <br />_l.as orvncrol'thcprol)crly.ortnycnrployccswithw:rgcsaslhcirsolcconrpcnsalion.rvillrkrttrcworkarxlthcstruclltrcisnot <br />inlcrulctl or oll'crctl lirr salc (Scc.7044. Ilusincss arrtl Prol'cssions ('odc: 'l'hc Cirrrlrilclor's Liccnsc l-aw docs not apply lo att owncr ol' <br />thcpnrJrcrty whobuildsorirrrJrrorcsllrcrcrxr.andwh()rkrcssuchurrrkhirnsell'orhcrsclforlhroughhisorhcrownemployccs. <br />provitlcd thal such irnprrvcrtrnls arc rxrl iltlcndcd or olll'rcd ltrr salc. lf. hos'cvcr. tlrc huikling rlr irrrprrlvcntnl is sold u'ithin onc ]'c:.rr <br />ot'corrphtirur. lhc Owncr lluildcr will havc thc burdcn ol'proving lhal hc or shc rlirl not huikl or irrprovc lhc pnrpcrty ttrr tlr'purposcol' <br />salc). <br />-1. <br />aso\r'ncrol'lhc propcrty. arncxclusivclycontractirrg with liccnscd conlrilcl()rslo conslruct lhc projccl (Scc. 7014. Ilusirtcss <br />artrl Pnrll'ssirrt(bdc: f'hcColrlraclor'sl.iccnscLarvdocsrrotapplyl()ilno$'ncrol'prolrcrtys'hobuiltlsorintprovcslhcrcon. <br />artrl who contracls lbr such projccls with a Contraclor(s) liccnscd ;lursuartl to lhc C'ontraclor's Liccttsc [.aw;. <br />_l arn cxcrnpl undcr .Scction_. Il. & I'.('. lirr lhis rcasorr. <br />l )lle ( )u rtt.r. <br />WORKERS' COMPENSATION <br />NECLARATION <br />I hcrcby alTirm under pcnalty of perjury onc of thc following declarutions: <br />-l <br />havcantl will maintainaCcrtificutco[ConscnttoSclf-lrrsurclirrworkcrs'corrrpcnsalion.ils providcdforbyScctionSTfi)ofthc <br />Llbor Codc. lirrlhc pcrforrrurncc of thc work for which thc pcrnril is issucd. <br />_l have and will nrainlairr rvorkers'corrrf^-nsalion insurancc. ils rcquired hy Scclion -37(D of lhc l;rbor Codc. for llrc pcrlormancc ol' <br />thc work tor which this pcrrnit is issucd. lVly w<lrkcrs' conrpcnsation insurancc carricr and grlicy nunrhcr arc: <br />Policv Numbcr: Exoires: <br />_l certify lhat in thc pcrfornunce of the work for which this pcrmit is issued. I shall not crnploy any pcrson in any manncr <br />so as lo heconrc subjcct to thc workers' compcnsation laws of California. and agrcc lhat if I should becornc subject to thc <br />workcrs' compcnsation prnvisions of Seclion 37fi) of thc labor Codc. I shall. forthwith comply with thosc provisions.. <br />WARNING: Failure to sccure workers' comlrcnsation coversgc is unlawful. and shall subject an employer to criminal pensltics and <br />civil fincs up to one hundred thousand dollars ($100.0001. in addition to the cost of com[rcnsation. darnages as providcd for the <br />Scction 3076 of thc l-abor Code, intercst and attorncy's fccs. <br />l):rlc: A;lplicunl: <br />LICENSED CON'IRAC'I'(IR <br />DFCLARA'TION <br />I hcrcby atllrrn undcr pcnalty of pcrjury lhal I am liccnsr'cl under provisiort of Chuplcr 9 (cornnrcrtcing witlr Scction <br />ol' thc Busirrcss and Prol'cssions Codc. and nry liccrrsc is in lirll ftrrcc and cftl'cl. <br />D <br />I <br />7m0) of Division 3 <br />License Class: Liccnse Number: <br />('oltl rirclor. <br />W <br />I hcrcby aIfirm under pnslty of perjury thal thm is r constructk n hnding agency for the [Efomnce of thc work for which lhis Imit is <br />issued (56. 3097, Civ. C.). <br />Lendcr's Nanrc: <br />l-crttlcr's Adrlrcss: <br />APPLICAN'I DECLARATION <br />I trrcby alTirrn under pcnalty of pcrjury onc of lhe following dcclarations: <br />Dcrnolit ion Pcrnrils-Asbcslos Notillcat ion Fcdcral Rcgulations (l'it lc 40. Part6) <br />-Rcquired <br />[-cttcr o[' Noliticalion <br />-l <br />cenify thsl Ihe fcdcnlrcgulations rcgording rsbcstos rcflrval trrc not applhshlc to this projel. <br />-l <br />enify lhal I havc rcad thir application ald state that thc abovc informtion is corcl. I aere to omply with all City and County <br />ordinsres dd Stste tjws rclating to buiHirrg conslruclk n. &d hcrcby sulhorirc rcpresilativcs of lhis Cily rnd Counly lo cnts utnn thc <br />abovc rentiorcd pmpcrty for irslrcrtion purFn$s. <br />Appllml or ASenl Slgnolurc: Drle:- <br />Permllee name (print): <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf Ioor <br />Buildinq Sewer <br />ArealStorm Drain <br />! nterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />I <br />POOL/SPA <br />P-trap/Drain Line <br />Main Drain/Pool Pipinq <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />I <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewerl}ap <br />Back Flow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release <br />FINAL <br />Notes, Remarks, Etc. <br />I <br />!