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PLUM BING.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BI'TLDER DELCARATION I hercby sllirm under penalty of perjury thst I m exempt ftom the Contr8ctoN' Licns kw for the following IEea (Sc.7031.5 Business ard hofession Codc): Atry City or County whhh requires a permit to @nstruct, 81t6, imprcve &mli,sh or rcpair my strucfirc. prbr to its isuece, rlso rcquircs the spplicant for such pemit !o file r sigtrcd stalcmnt that hâ‚¬ or shc is licensed pus6t to the provisions of the Conbrctor's Lbensd Law (Chrpter 9, Comncir8 with Setion 7000 of Division 3 of the Buircss md Pmfessions Code) or that hc or she is exempt thgefrom ud the bssis for the 8llegcd eremptbn. Any viohtion ofS&tion 7031.5 by any 8pplicant for a pemir subjEts the applic&nt to I civil pcnalty of not mre thm live hundrcd douars ($500). _I, as owner of the property, or my employees with wages as their sole compensation, will do tlrc work and thc stnrcture is not intended or offered for sale (Sec.7044, Business and Professions Code: The Contractor's License l.aw does not apply to an owner of the property who builds or improves thereorL and who does such work himself or herself or through his or her own employees, provided that such improvenrcnts are not intcndcd oroffered for sah. If, however. the building or improvement is rcld within onc )rcar of completion, the Owner Builder will have the burden of proving that he or she did not build or improve the proprty for the purpose of sale). _1, as owncr of the propcrty, am cxclusively contracting with licensed contractors to construct the project (Scc. 7W, Busincss and Profcssion Codc: The Contractor's License Law does not apply to an owner of pro;rcrty who builds or improves thercon, and who contracts for such proicts with a Contractor(s) licensed pursuant to the Contractor's Liccnsc Law). -lamexcmptunderSection-'B.&P.C.forthisrcason.n-a^. WORKBRS' COMPENSATION DECLARATION I heybV affirm under pcnalty of perjury onc of the following declarations: V nou" and will maintain a Certificatc of Consent to Self-lnsurc for workers' compcnsation, as providcd for by Secrion 3700 of thc f-rUnr Code. for thc pcrformancc of thc work for which the permit is issucd. -l have and will maintain workers' compensation insurance. as rcquircd by Section 3700 of the l-rbor Codc, for thc perfonnancc of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: L i -Policy _l ccrtify that in thc pcrformance of the work for which this pcrmit is Lssued, I shall not employ any person in any manncr so as to become subjcct to thc workers'compensation laws of California. and agree that if I should bccome subject to the workers' compcnsation provisions of Section 3700 of the l-abor Code, I shall, forthwilh comply wilh those provisions.. WARNING: Failure to sccurc workcrs'compcnsation coveragc is shall an crnployer to criminal Jrcnaltics and civil fines up to one hundrcd thousand dollars ($100.000), in Scction 3076 of the krbor Code, interest and attorney's fees. damages as providcd for the 7 n-q^}[ I hcrcby affirm under penalty of perjury that I arn licensed 9 (comnrcncing with Scction 7000) of Division 3 Iof thc Busincss and Professions Code. and my licensc is in cffcct. lo tsobfLiccnse,t I o ,)-L1 I hnlo, I hcrcby affirrn undcr penalty of perjury that thcre is a construction issucd (Sec. 3097, Civ. C.). Lcndcr's Name: agcncy for thc performance of the work for which this pcrmit is lrndcr's Address: APPLICANT DECLARATION I hcrcby affinn under pcnalty of pcrjury onc of thc following dcclarations: Demolition Pcrmits-Asbcstos Notitication Fcdcral Rcgulations (Title 40, Part6) _Rcquircd lrttcr of Notification _l certify that the f'cdcralrcgulations asbestos rcmovalarc nol applicable to this projcct. information is corrcct. I agrce to comply with all City and County hcrcby authorizc rcpresentativcs of this City and County to crPter upon the abovc mcntioncd propcrty for Applicant or Agent )V hn(Pernritee nanre Io Ct-- Dale:L 7n\- 2( UNDER GROUND Waste & Vent Water-Under floor Gas-Underf loor Buildinq Sewer ArealStorm Drain I nterceptor/ Clarifier TOP OUT Waste & Vent Water Piping Gas Pipinq Roof Drain Tub/Shower Test Rouqh Water Heater POOL/SPA P-trap/Drain Line lVlain Drain/Pool Piping Fill Line/Back Flow Pool Heaterlcas Line Miscellaneous Gas Service Water Service Lawn Sprinkler Sanitary SewerlCao Back Flow Device Rough Plumbing Final Gas Test Meter Release FINAL b ?g.A oa*4t Notes, Remarks, Etc. -b