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PLUM BING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELC/IRATION <br />I hcrchy affirm undcr pemlly of Jf,rjury that I u cxempa from ah€ Con&rcto6' Liere Lsw for rhc following ren LSe.7031.5Busincss ard Prcfcssion Codc): Atry City or Conry whhh rcquires ! permir to @nstret. slt6. improw, &mlirh or rcpefu my <br />structw, prbr to its issre. also requircs lhc spplket for such pcmil to tik I sigrcd stal€mot thst hc or slE b liccnsd plmant <br />lo the prcvisions of fte Contractor's Licensd lrw (Ctapter 9. Comncing with Setion 7000 of Division 3 of thc Busircss md <br />PDfcssionsCode)orthailEorsh€ircrcmptthercfrcmsrdlhcbasisforthcrlbgcdcrcmption. AnyviolationofsstbnT03l.5bysny <br />8pplicsnt for I pemii subj$ts ahc spplicant to s civil penalty of mt mrc lhm five hundrcd dollss ($500). <br />? <br />-1. <br />as owncr of the property. or my cmployccs with wages Bs thcir soh compensation, will do thc work Bnd the structure is rnt <br />intcnded or offered for sale (Serc.7044, Business and hofcssions Codc: Thc Contractor's License Law does not apply to an owncr of <br />the proprty who builds or improves thcrcon, and who docs such work himsclf or herself or through his or hcr own cmployees. <br />providcd thal such improvenrcnts arc nol inlcndcd or offcred for salc. lf. howcver. thc buiHing or inqlrovcnrnt is sold within onc )rar <br />of complction, the Owncr Buildcr will have the burden of proving thal he or she did not build or inprove thc property for the purpose of <br />salc). <br />-1, <br />Bs owncr of thc property, am exclusivcly contracting with licensed contractors to construct thc project (Sec. 7W, Business <br />and Profession Code: Thc Contractor's Liccnsc l-aw does not apply lo an owner of propcrty who builds or improvcs thereon, <br />and who contracts for such pro.ytrcts with a Contracto(s) licensed pursuant to thc Contractor's License [aw). <br />-IamexemplundcrSection-'B.&P.C.forthisreason. <br />hoIo. <br />WORKE'RS' COMPENSAT|ON <br />DECI ARATION <br />I hereby affirm under pnalty of perjury onc of the following dcclarations: <br />-l <br />have and will maintain a Ccrtifrcate of Consent to Self-lnsurc for workers'compensation, as provided for byScction 3700 of the <br />labor Codc. for thc pcrformancc of thc work for which thc permit ls issucd. <br />37fi) of the Labor Code, for the pcrformancc of <br />and ynlicy number arc: <br />Policy --()L -.-t /lo -)-z? <br />-l <br />ccrtify thal in thc prformance of the work for which this pcrmit is issucd, I shall not cmploy any pcrson in any manncr <br />so as lo bccornc subjcct to thc workers'comlrcnsation laws of California, and agrce that if I should becomc subict to the <br />workcrs' compensation provisions of Scction 3700 of thc Labor Code, I shall, forthwith comply with thosc provisions.. <br />WARNING: Failurc to sccurc workcrs'compcnsation coveragc is unlawful, and shall subject an employer to criminal Jrcnaltics and <br />civil fincs up to onc hundrcd thousand dollars ($100.000), in addition to the cost of compensation. damagcs as providcd for the <br />Section 3076 of I-abor intcrcst and <br />C-t <br />DECI ARATION <br />I hercby affirm under pcnalty of perjury that I am liccnsed undcr provision of Chapter 9 (comnrrrcing with Section 7m0) of Division 3 <br />of thc Busincss and Professions Code, and my license is in full forcc and effect. <br />ftl %rqLiccnscNurnbcr: <br />I hcrcby affrm under Fmlty of pcrjury that thcrc is a onstructhn hnding agency for thc lrcrforuc of thc work for which this lErmit is <br />issucd (Se. 3097, Civ. C.). <br />kndcr's Nam: <br />Lcnder's Address: <br />APPI ICANT DECLARA'I'ION <br />I trcrebyafflnnunder penalty of perjury orc of the following declarations: <br />Demolition Pcrmits-Asbestos Notification Fedcral Regulations (Title 40, Part6) <br />-Requ <br />ired l.etter of ltlotifrcation <br />-lld.rty <br />that thc fcdcralrcgulations rcgartling asbcstos rcmovalarc not applicablc to this projcct.7(/ I ccrrify that t havc rcad this application ancl statc that thc abovc inforrnarion is correct. I agrec to comply <br />ordinances and State Laws relating to building construction. and hcrcbyauthorizc rcprcscntatives of this City <br />abovc mcntioncd proJrcrty for <br />Applicant or Agent <br />I I <br />I'emrilee name <br />\t <br />with af City and Qunty <br />and C{unty to cntf upon the <br />q lzo, lz ( <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf loor <br />Building Sewer <br />ArealStorm Drain <br />I nterceptor/ Clarifier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rouqh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />It/ain Drain/Pool Pipinq <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler I ,O- <br />Sanitary Sewer/Cap le 7t b*Y fl <br />Back Flow Device I <br />Rough Plumbing <br />Final Gas Test <br />Meter Release I I 2, <br />FINAL tc I -l '71 DVT?,27 <br />Notes, Remarks, Etc <br />Owner:_ <br />fb