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PLUMBI NG.I NSPECTOR RECORD <br />APPROVALS DATE ID/S!G COMMENTS OWNER BUILDER DETIARATTON <br />I hacby affm und6 paslty of pqjury that I m qmpt ftom thc Contnctots' Licmc law for thc followirg twn (Se.7031.5 <br />Buine ard Prcfc*rion Codc): Any City or Courty which rcquiB 8 pqtnit to @nstruct, ahs, iqrovc damlish or npeir uy <br />struclE Fior to its iswcc, alrc rcquis thc appli@t for such pcmit to filc I signcd statmat that hc or $c b licrucd puman <br />to thc prcvisioN of thc Contrrctor's Liqscd Lrw (Chaptc 9, Comming with Setion 7000 of Division 3 of thc BwitB ed <br />Prcf6siom Codc) or thar hc tr shc is qmpt thqc&oD and thc bab for thc sllcgcd qartrion. Any violation of Sctiotr 7031.5 by uy <br />applicmt for I pamit subj*ts thc applicut to a civil pcmlty of not morc thm frvc hundrcd dollrs ($500). <br />_1, c oma of thc Fopcny. tr my mplo]6 with wag6 a thcir $lc smpqBdion, will do $c wort ad thc stn ctrc b not <br />intodcd or offqcd for slc (Sc.7044. Buine od ProfcaioB Codc: Thc Cortrsc{or's LiccB t w do6 rct eply to u omq of <br />thc propqty who hrilds or inpros tltaou md who doq uh w* hiruclf or hmlf or thmugh hb or lE om mplolcc, <br />providcd that such improEr@ts e rct intqdcd or olfuld for slc. If, how, thc hilding or irproErult is sld within onc 1a <br />of cotrplrbrt the Ownq Builda *ill havc thc hrdor of poving tha hc u shc rlil mt hrild or itqrcrc lhc poFty for thc FrpGc of <br />elc). <br />-1. <br />I ow of thc propqty, u qclwivcly @trtrrcling with lisscd contrrtoB to @Ntruct thE Folrl (Sc. 7(N4, &BinB <br />and hofixsim Co&: Thc Contrac{or's Licffi L8w do6 not apply to o oma of propcly who buil& or imprcvB thson, <br />md who ontracls for such projcB with I Contrrcto(s) licstscd pEuet to thc Cotrtraclor's Licmc ttw). <br />_l am excmpt under B.& <br />DT]CI,ARATION <br />I hereby affrrm undcr penalty of perjury one following declarat ions : <br />-l <br />have srd will maintain a Certificatc of Conscnt to Self-lnsure for workers' compcosation, as trovidcd for by Section 3700 of the <br />L^abor Code, for the pcrformance of the work for which the pcrmit b issued. <br />-l <br />have and will maintain worken' compssation insurancc. as roquircd by Section 3700 of the lahor Codc, for the pcrformance of <br />the work for which this pernrit is issuod- My workers' compensation insurance carricr and policy numhr are: <br />Policy Numbcr: Expires: <br />_l certi$ that in the performance of the work for which this pcrmit is issued" I shall not employ any pcrson in any manner <br />so as to bccome subject to the worters' comp€nsation laws of Californra, and agree that if I should become subjcct to the <br />workers' comperuation provisions of S61ion 3700 of the labor Code I shall, forthwith comply with those provisioos.. <br />I <br />WARNING: Failure to secure workers' compexsation coverage is unlawful. and shall subject an anployer to criminal perrahi& and <br />civil fines up to onc hundred thousand dollars ($ I in addition to the of compensation, damages as provid( b?or the <br />Section 3076 tabor Code. interesr and\I 0 <br />DECI.,ARATION <br />I hereby aflirm under penalty of pcrjury that I am liccnsed under provision of Chapto 9 (cornmencing with Section 7000) of Division -3 <br />of the Business and Professions Code. and my license is in full force and effett. <br />Liccnse Class: License Number: <br />CONSTRUCTION LENDING AGFNCY <br />I hereby aflirm undo penalty of pcrjury that th6c is r construction lcndiog agmcy for the pcrfomcc of thc work for which this psmit is <br />issucd (Sa. 3097. Civ. C.). <br />Lender's Name: <br />I-cnder's Ad&ess: <br />APPLICANT DECLAITATTON <br />I hereby affinn under penalty of perjury one of the following declarations: <br />Dernolition Permits-Asbestos Notification Federal Regulations (Titlc 40. Part6) <br />_Required Letler of Notification <br />_l certi$ that the federal asb€stos removal are not applicable to this project. <br />_l ccrti& that I havc read this with all City and County <br />above mentioned property for <br />Applicnnt or Agent <br />Permitee nnme <br />and state that <br />and County to enter upon the <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Building Sewer <br />ArealStorm Drain <br />I nterceptor/ Cla rifier <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 />Main Drain/Pool Pipinq <br />Fill Line/Back FIow <br />Pool Heater/Gas 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 I <br />Meter Release n <br />FINAL 1'Aa)br(f n <br />Notes, Remarks, Etc.V <br />I <br />(lontraclor: <br />Pt+*A/ <br />,*", tt lb/oLo