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PLUMBI NG.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEITARATION <br />I hmby affm unda poahy of pa;jury that I m qmpt tom thc Corilnc{oB' Licce lrw for thc fonowiog tE$t(Se.7031.5 <br />Buincs and Prof6ion Codc): Any City or County which rcquirc a pcmit to coniruct. alt6. iEprovc. dorclirh or npeir my <br />struourc.priortoits isumc,alsorcquircthrqplimtforsuchpamhtofilcasignodstdmtthatrorrbcbtc&sodpuiuul <br />to thc provisioE of thG Cootsscttr's Licmsod kw (Cfupt6 9. Commiog with Setioo 700O of Division 3 of thc BuitB ell <br />Profsioro Co&) or thst hc or shc b qmpt thqcfiom md thc basis for thc dlcgcd qmption. Any violation of Sctbn 7031.5 by my <br />applicmt for a pcnnit subjets thc applicet to 6 civil pcnalty of mt morc the tiv€ hudttd dollm (5500). <br />Dldl, * o*o of thc Fopqty, or my mplo)6 with wagB s thcir mlc ompenstion, will do thc wut and 0E suudrc b rct <br />inrdrdcd or ofrcred for elc (Sc.7M4, Buins ud hof*ioro Codq Thc Conlrsclor'r Lic@c kw do6 rot rpply to il om6 of <br />thcplopqty whobuildsorimFovctluon ardwhodsswhwr*hirelforhmlforthrcughhisorhaoMcmploycB. <br />prcvidcd that such imgovqEfs e mt htqdcd or olfqcd fur sb. If, lDwrE, thc hilding or imFowt is $ld within onc ]@r <br />of ompkiion, thc Om6 Buikk will luw [rc hldar of pmvirg ttra hc c shc dil mt hiH or improw thc prcpaty for thc purpo* of <br />slc). <br />-1. <br />u omq of thc Fopcty, m ecluivcly contracting with licascd cotrtratoE lo cooltruct thc poixt (Se. 7044, &Eins <br />ad hoftsir Cods Thc Comraaor's Licosc Law do6 lot spply to 6 omq of propqly who buil& or imprcv6 thso!. <br />ud who @ofets for such projcls with a Coilnc{o(s) licosod puEmt to thc Couttrlor's Lic@ Lrw). <br />-l <br />am under P.C. for this reason. <br />CE <br />I hcreby affrrm under penalty of pojury onc of the following <br />_l have and will maintain a Certificatc of Conscnt to SelGlnsure for workers' comp€nsation, as provided for by Section 3700 of the <br />I-abor Code, for the pcrfonnance of the work for which the pcrmit is issued. <br />_l have and will maintain workers' compcnsation insurance. as required by Section 3700 of the tabor Code, for the pcrformance of <br />the work for which this pcrmit is issuod My workers' compensdion insurance carricr and policy numh are: <br />Policv Number: Exoires: <br />Dft.*iff that in the performance of the work for which this permit is issucd, I shall not employ any pcrson in any manner <br />so as to become subject to the workcrs' comperuution laws of California, and agrec that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code, I shall, forthwith comply with thosc provisions.. <br />WARNINC: Failure to secure workers' compensation coverage is unlawful. and shall subject an ernployer to criminal pcnalties and <br />civil fines up to onc hundred thousand dollars ($100,000). in addition to thc cost of compensation. damages as provided for the <br />Section 3076 of the labor Code. interest and attorncy's fees. <br />I hereby affrm under pcnalty of perjury that I am licensed Chapto 9 (commencing with Scction 7000) of Division 3 <br />of the Business and Professions Code, and my license is in full force and effect. <br />License Class: License Number: <br />W <br />I h@by arfim ud6 pcnahy of pcjury tha th@ is I @rdruclbtr lcoding agocy for thc pafomcc of thc mlt 6r which thi! Fmit ii <br />issucd (Sc. 3097. Civ. C.). <br />Lender's Name: <br />l.codcr's Ad&css: <br />APPLICANT DECLARATION <br />I hercby aflinn under penalty of pcrjury one of the following declarations: <br />Dernolition Perrnits-Asbestos Notification Federal Regulations (Title 40, Part6) <br />-Rcquired <br />Letter of Notification <br />-I <br />cqtiry that thc fcdGal rcguhtioB rcgadhg ab6tG mval ac trot applicablG to this projcl. <br />ll(t ccti& thar I luvc rqd this application ed stat€ rhd thc abovc itrfotrnstion is corct. I 8g16 to @mply with rll City ed Couty <br />ordlmca ud Statc L:w rclding to building coir*ructiolt Ed hqrby 8uthorizc rcpEatativc of thir Cily ud Courty to 6t6 lpotr tlE <br />above mentioned property for <br />Applicrnt or Agent <br />I'ernritee ntrme <br />.}6 lr[ <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Building Sewer <br />Area/Storm Drain <br />I nterceptor/ Cla rifier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />Main Drain/Pool Piping <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewer/Cap <br />Back FIow Device <br />Rouqh Plumbinq <br />Final Gas Test <br />Meter Release lf ,l /t <br />F!NAL k \r,q xt EM#,IS Y <br />Notes, Remarks, Etc.I <br />-+ <br />Carrier: <br />o.,., r 5[t(\211t <br />Contractor: