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PLUM BING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS Om6-Build6 Debntion o <br />I hscby rfrum unds pcBhy of pcrjury thlt I m ffipt fom thc Contrrtton' Lkxre lrw for t\e following mtr (G7031.5 Buio6t <br />md Profarioo Codc): Any City or County which rcquirc r pamit to osuuct, rlts, improvc' dcmolirh or rcprir uy rtructuc Fior o itl <br />irsuncg rlso rcquirs thc applimt for ruch ptrmit to filc r signcd mtcmtr thrt hc or 3tE i! li@md puruUt to thc pmvisiou of rhc <br />Conrraor's Limed hw (Chapta 9, Conmcrcing with Scaioa 7000 of Divirion 3 of thc Buin6r Id ProfdbE Codc) or thrt hr or <br />she ir rempt thacfrom ard the buil for thc rllcgcd acmptbn .Any vioLtiotr of S€tion 7031.5 by [y spplimt for r Fmit subj*r thc <br />rppliont to r civil pcmlty of mt mrc ttcn fivc hundrcd rl,olhn (t500). <br />_I, u ow of thc propcrty, or my cmployc with mgc u thcir :olc ompcmtio4 will do thc mrt rnd ths ltructuc is mt iiladcd <br />or offacd for slc ( 36.70114, Buiu! ud Profesioro Codq Thc Contrrcior'! Limc hw du mt rpply to m ow of thc prcpaqr <br />who buil& or improB tlrcr@q rnd who do6 ruch mrk hiroclf or h€rclf or tluough hi! or hs ow mploys, prcvidcd dut such <br />improwmcnr rc not intcndcd or otrscd for nlc. If, howcu, thc building or improwmcnt ir rcld within orc yw of omplaio4 the <br />Ow-Builds will luve thc bu&n of proving thrt hc or rhc mt build or improw for thc purpolc of slc). <br />y6o* A*prop<ty, rm aclusivcly @ntnding with li€Ecd ontnctotr to ost uc th€ p(ojdt ( Sa 7044, Buins ud <br />Prcfqion Codc: Thc Contn tor'3 Liccre hw d6 nor rpply to u ow of propaty who buildt or improE th66n , rnd who <br />oilncls for such prcjcts with r Contnclo(s) licocd purrunt io thc ContEator'! Licce hw.). <br />_I am exempt under Section_o <br />I hereby affrm under penalty of pcrjury one <br />_I hrvc ud will mintlh r Cqtifietc of CoE6t !o Sclf-Iruurc for mrkf,' omFmtioq u providcd for by Scction 3700 of thc <br />bbor Codq for thc pqfomm of thc mrk for which thc psmit ir issucd <br />_I hrvo rnd will roint in workq!' ompcurtion iruunncg u rcquircd by Serion 3700 of th. hbor Codg for thc pdforrme of thc <br />mrl for which thir pmit ir isud. My mrkm' ompcnretion iilrme fficr rnd policy Nmb6 uc: <br />Policy Number: Expircs: <br />(This section need * 00) or less) <br />Vrdrrrthat in the pcrformance of the work for which this pcrmit <br />bocame rubjoct to the workem ' compcnsation laws of Californtq and <br />is issued, I shall not employ any in any manner so as to <br />to the workers' <br />compensation provisions of Scdion 3700 of thc Labor Code I L <br />WARNING: Failure to secure workers' compcrurEtion <br />fines up to one hundred thousand dollars ($100,000),in r <br />the Labor Code, interest and attorney's fees. <br />cover&ge is and shall subject !o criminal penalties and civil <br />addition to the cost of compensatior\ damages as provided for the Section 3076 of <br />LICENSED CONTRACTORS DECLARATION <br />I hcrcby affirm unds pmhy of pqjury thrt I rm lieN€d adcr provision of Chrpts 9 (omcncing with Scrion 7000) of Division 3 of <br />thc Buircs and Profcssioro Codc, ud my liccrc ir in full fore ud cfrct. <br />Liere Cbs:_ Liensc Numba _ <br />Drtc: Contnctor: <br />W <br />I hccby rfiirm unda pcnhy of pdjury thst thsc i! r @Btruc'tion hoding agcmy for thc pqfomne of thc mrt for which this pamit is <br />is$cd (Se. 3097, Civ. C.). <br />kndq's Namc: <br />Lender's Address: <br />APPLICANT'S DECLARATION <br />Demolition Permits-Asbestos Notification Federal Rcgulations (Title 40, Part 6) <br />_ Required Later of Notification <br />I sji& tht fte ftdol rcgulatiou rcgudirg ubctor rmnl rc mt rpplioblc to Od! projcct <br />U(* *rrUnred thir epptietionrnddrtcthrttlErbow hfomriotr is 6rc(L IrSrcto6mply withrll Cityud Couty <br />ordinances and State [aws relating to of this City and County to entcr upon the <br />above mentioned property for <br />Applicant or agent <br />Permittee name (print):)< <br />A <br />UNDER GROUND I <br />Waste & Vent z/zb ruvD <br />Water-Underfloor (rl / <br />Gas-Underfloor <br />Building Sewer <br />Area/Storm Drain <br />I nterceptor/ C la rifier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Pipeing <br />Roof Drain //I <br />Tub/Shower Test 7M/0fi .ffilll) <br />Rough Water Heater l'\r/ <br />POOUSPA <br />P-trap/Drain Line <br />Main Drain/Pool Piping <br />Fill Line/Back Flow <br />Pool Heaterlcas Line <br />Misc <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary SewerlCap <br />Back FIow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release <br />o f n /^f/,/^-.* rA <br />FINAL 7/7 / d(Ul%ttr,b{f// g) <br />Notes, Remarks, Etc. <br />J <br />/ <br />L