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PLUM BI NG.I NSPECTOR RECORD APPROVALS DATE ID/S!G COMMENTS OWNER BUILI'ER DEI,CARATION I hmby alfm und6 pcnrlty of pGjury thd I m qmp fiom thc ContracloB' Licre lrw for thc following rctr (Ss.7031.5 Buincs and Profeion Codc): Any City or County which rcquir6 I pqmit to construct, dtq, improvq damtish or npair uy structurc. prior to its isumc, also rcquirc rhc eplicut for such pqrrit to filc 8 signad ststmt that hc or shc b licqEd plmail to thc prcvisioB of thc Contr&tor's Liccnscd law (clEpt6 9. Comacing with Scrion 7000 of Divirion 3 of thc Buire md PrcfesionsCodc)orthathcorshciscxmptthqcfiommdthcbosisforthc8ltcgcdqmption. AnyviolationofsctionT03l.5byey applicsntforapqnitsubjctsthc spplicmttoacivilpmlyofmtmrcthulivchundrcddollm($500). -1, rs owner ofthe property. or my cmployeca with wages as their sole compansation, willdo the work and the structure is not intended or offered for sale (Sec.7044. Business and Professions Code: The Contractor's Licerse l-aw docs not apply to an owner of the pmperty who builds or improvc tlrcreon, and who docs nrch wort himself or hcrsclf or through his or her own crnployccs. provided that such impmovernents arc not intendod oroffcrod for salc. I[, howerrer. the building or improvanrcnt is sold within one ]car of complaion. the Ovner Builder will have the huden of proving that he or she did not build or improve the propoty for the purposeof sale). _1. as owner of the property. am exclusively contracting with licensed contractors to construct the project (Sec. 7044. Business and Proftssion Code: The Contractor's License Law does not apply to an owner of property who builds or improvcs thereon. and who contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's Licensc l-aw). -l am exempt under B.& DI'(]LAILt'TION I hereby affirm under penalty of pcrjury one declarations: _l have and will maintain a Certifrcate of Consent to Self-lnsure for workers' compcnsationr asi provided for by Section 3700 of the I-abor Code. for the performance of the work for which the pcrmit b issued. -l have and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for thc pcrformance of the work for which this permit is issued. My workers' compqrsation insurance carrier and policy number are: Policy Number: Exphes: -l certify that in the performance of the work for which this permit is issued, I shall not anploy any pennn in any manner so as to become subject to thc rvorkers'compensation laws of California. and agree that if I should become subjoct to the workers' compensation provisions of Section 3700 of the l-abor Code. I shall, forthwith comply wilh thosc provisions..s WARNTNG: Failure to sccure workcrs' civil frnes up to one hundred thousand Section 3076 of the l-abor Code, intcrest compensation coverage is unlawfuL and shall subject an to and thedollars ($100.000). in addition of compensation.for and attorney's fees. 7l DECII\RATION undcr provision of Chapcr 9 (commorcing with Section 7000) of Division 3I hereby affrm undcr pcnalty of perjury that I am licorscd clf the Business and Professions Code, and my license is in full force and effect. License Class: License Number: flolo. CONSTRUCTION LENDING AGENCY I hcby affim undo pcnslty of perjury that th@ is a @nstruclion lcrding agmy for thc pqfommcc of the work for shich lhis psmit b issucd (Sa. 3097, Civ. C.). lrnds's Nme: I crttlct 's ,,\rkltcss: APPLTCANT DECLAfuITION I hereby affirm under penalty of perjury one of the following declarations: Dernolition Permits-Asbestos Notifrcation Federal Regulations (Title 40. Part6) _Rcquired Later of Notification -l ccrtify thal the federal regulations rcgarding asbestos rcmoval are not applicable to this projed. _l certify that I have read this application information is correct. I agree to comply with all City and County r rep,resentatives of this City and County to ertcr upon theordinances and State l-aws relating to above mcntionod property for Applicnnt or Agent Permitee nRme and hereby authorize b.a\ UNDER GROUND Waste & Vent Water-Under floor Gas-Underfloor Building Sewer ArealStorm Drain I nterceptor/ Cla rifier TOP OUT Waste & Vent Water Piping Gas Piping Roof Drain Tub/Shower Test Rough Water Heater POOL/SPA P-trap/Drain Line Main Drain/Pool Pipino Fill Line/Back Flow Pool Heater/Gas Line Miscellaneous Gas Service Water Service Lawn Sprinkler Sanitary SewerlOap Back Flow Device Rough Plumbing Final Gas Test Meter Release ^/ /I t I A FINAL ,ru!/2-,htukfi '/av Notes, Remarks, Etc. Contraclor: n \-q tgn*on