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PLUM BING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDEN DELCARATION <br />I hercby 8ffm under Fnilly of pcrjury thal I m cxcmpt frcm the Conrrero6' Lhms lrw for rhe folbwing rcNn (Str.7031.5 <br />Busircss rird Profcssion Code): Aoy City or Counry whth requires s Frmil ao @nstruct. alts. imprcw. &mlish or rEJxir my <br />strudw, pdor to ils issure. rko requircs the spplicml for such pemil lo fih I sigrcd ststemnt thst hc or rhc b licctrsd plmrnt <br />to tlE pmvisioN of thc Conrrcttr's Lbenscd tlw (Chapts 9. Comrcrcing with SEtion 7(m of Division 3 of thc Burircsr o-d <br />Pmfessions Codc) or lhat hc or she is exerpt thcBfrom srd thc b&ik for the slleged cxcmption. Any violstion of S€lkrn 703 1.5 by any <br />applicsnt for a pemit subj$ts thc rpplicant to a civil pculty of mi mrc th& fivc hundrcd dolles ($5@). <br />l&, u owncr of the prcpcrty, or my emploles with wsgc! &s thcir sh comlEnsstion. will do tfr utrk and tlE stnrtw h mt <br />intendcd or ollmd for slc (Se.7(X4, Busircss ud Pmfcssbns Codc: Tha Contrsctor's Lbcns hw dms mt ryply to u owrcr of <br />the lrcFrry wlE htills or irprcE th.@tr 8rd who dcs ffih m* himrclf or her$lf or thrcugh his or ls own empk lEcs. <br />prcvided fiar sEh imprcvrmnls re rct iilcndcd trofu ftr slc. lf. how. thc huilding n itrprowmnr is sld withh orc )ar <br />of otrphrio& the Owm Buil{cr will haw thc h[dm of prcving that h tr dr dit mt hfi tr hprcrc thc poFry for tlE Frpos of <br />slc). <br />-1. <br />us owncr of the proprty. anr cxclusivcly contracting with liccnscd conlraclors to construct thc projcct (Scc. 7W, Busincss <br />and hofcssbn Code: The Contractor's License Law docs nol spply lo an owncr of properly who builds or improves lhereon. <br />and who contracts for such projccts with a Contractor(s) liccnsed pursuant to the Conlractor's License L:w). <br />I am cxcmnt <br />, <br />Scction-. B. <br />o tl*n..,-ts <br />}VORKI.: RS' COt\ I PENSA'TION <br />DECI ARATI(IN <br />. I lqhbyaflirmundcr Fnslryof lHjuryorcof thc followinS dsl@tions: <br />K**,,lminr.in!ccrtificarcofconsnrtosclf-lnsurcforworkss'orrpcnsdion,s lrevidedforbyssrion3T00ofrhc <br />jrtnr Cde. for the pcrfomrcc of thc work for which lhc lErmit is issued, <br />-l <br />havc and will maintoin workcrs' cornpcnsalion insurancc. &s rcquircd by Scction 37fi) of the Labor Codc. for thc pcrfornuncc of <br />lhc work for which this pcrrnit is issucd. My workcrs' compcnsation insurance carricr and policy numbcr arc: <br />thal in thc pcrformance of the work for which this pcrmit is issucd. I shall not employ any person in any manncr <br />of California. and agree that if I should bccome subjccl to thcso as to bccorne subjcct to thc workcrs'compensation laws <br />workers' compensalion provisions of Section 3700 of thc [:tnr Codc. I shall. tbrthwith comply with thosc provisions.. <br />llt<lWARNING: Failurc to sccurc workcrs' <br />civil fincs up to onc hundrcd thousarrd thc <br />Scction 3076 Codc, intcrcst and attorncy's l'ccs. <br />I <br />l)atc:2 JC <br />I trcrcby affirm undcr Jrcnalty of Jrcrjury that I am licenscd 9 (comrncncing with Sectbn 7m0) of Division 3 <br />of the Busincss and Profcssions Code. and my liccnsc is in tull forcc and cffect. <br />[,iccnsc Nunrhc'r: <br />I t..a,.,Conlractor: <br />W <br />I hercby affrm uidcr Fnllly of Frjury thlt tlre is I @nstruclion hnding agcrcy for the ,f,rfom of the wort for which this Fnnil h <br />issucd (Ss. 3$7. Civ. C.). <br />Lender's Name: <br />[,endcr's Addrcss: <br />APPI ICAN'I' DECLARATION <br />I hcrchy aflinn under pcnalty ol' pcrjury onc o[ thc f'ollowilrg dcclrral ions: <br />Dcntolition Pernrils-Asbcslos Noliflcalion Fcdcral Rcgulations ('l'itlc 40. Part6) <br />Rcquircd lrttcr oI Nolilication <br />Iterntilee <br />lhc <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf loor <br />Building Sewer <br />ArealStorm Drain <br />I nterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rouqh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />It/ain Drain/Pool Pipinq <br />Fill Line/Back FIow <br />Pool Heaterlcas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewerlcap <br />Back Flow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release <br />FINAL Id.+-A NrVIr)t <br />Etc.I <br />Lh<'r*$zP hlnfyd <br />Carrr2ffij/+ <br />Exoires: