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PLUM B! NG.I NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER IIELCARATION <br />I hcby affm undc pcnalty of pojury ihsl I m cxcmpt ftom the Contr.cloB' Licm hw for thc following rcen (Sc.7031.5 <br />Buinss ud Prcf*ion Codc): Any City or Couty which rcquirc 8 pqmit to snstruct. alta, imprcvc danolish or rcpair uy <br />structurc, Fbr to its ismcq also rcquim thc applicet for such pqoit to 6lc a 3igncd staldat tha hc or shc ir licrscd pwurt <br />to thc provisiorc of thc Contretor's Licerscd Law (Ch8pt6 9, Comocing with Sclion 7000 of Division 3 of thc Bwirc md <br />ProfsiomCodc)orthsthcorshcisqmptth@fromudthcbasisforthcallcgcdaopion. AnyviolationofserbnT03l.5byuy <br />applicut for a p6mit subjets thc applicmt to a civil pmlty of mt morc tho fivc hundrrd dollm ($500). <br />_1, as owner of the propcrty, or my emplo)€es with wagcs as their sole compcnsation, will do the work ard thc structurc is not <br />intcndod or off€rod for sale (Sc.7044, Business and hofcssions Codc: Thc Contractor's Licase [^aw does not apply to an owncr of <br />the propcrty who hril& or irFovcs theroru ard who do6 such wort himsclf or hersclf or through his or hcr own cmployecs, <br />providcd that such improvonents ae not intcndod oroffirad for sale. If, howwer. thc hitding or improvcmcnt is soH within one )&ar <br />of conpkxioru thc Oryner Buildcr will have thc hrdca of proving thd he or she did not build or improra the properqy for the purposc of <br />sale). <br />-1, <br />as owner of the propcrty, am exclusively contracting with licenscd contraclors to construct the project (Sec. 7044, Brsincss <br />and Prcftssbn Code: The Contractor's Liceose Law docs not apply to atr owncr of property who builds or improve thcreon" <br />and who contracts for such trojccts with a Contracto(s) licenscd punuant to the Contractor's Liccosc l^aq/). <br />-l <br />am exempt under Section-, B. & P.C. forthis rcason. <br />WORKEtrLS' COM PENSATION <br />DECLARATION <br />I hereby affrm under pcnalty of perjury one of the following declarations: <br />_l have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation, as provided for by Section 3700 of the <br />Labor Code. for the performancc of the work for which the pcrmit is issued. <br />_l havc and will maintain work€rs' compensation insurance. as required by Section 3700 of the labor Code, for the performance of <br />the work for which this pcrmit is issued. My workers' compensation insurance carrier and policy number are: <br />Policy <br />_l ccrti& that in the performance of the which this permit is issucd. I shall not amploy any person in any r-n5"' <br />should become subject to the t\tso asi to become subject <br />workers' compansation <br />to the workers'comporsation laws of California, and agree that if I <br />provisions of Section 3700 of the l,abor Code. I shall, forrhwith comply with thorse prov*ro,s;t- <br />WARNING: Failure to sccure workers' compensation is unlawful, and shall subjoct an onployer to criminal ponlties and <br />civil fincs up to one hundred thousand dollars in addition to the cost of damages as provided for the <br />Section 3076 of the labor Code intercst and fecs. <br />o,,", J lb/lozl <br />LI(] I,:N S ED ('ON'I'ITA(''I'O R <br />DECT AIL{TION <br />I hereby aflirm under penalty of pcrjury that I am lic€osod under provision of Chapter 9 (commencing with Section 7000) of Division 3 <br />of the Business and Professions Code, and my licensc b in full force and cffd. <br />a <br />License <br />7 / 0 /toztDate: <br />W <br />I hmby alnm mdc psulty of pqjury thai th@ is a @odructbtr kading agacy fur thc pqfomcc of thc rcrl &r which tbis psmit ir <br />b$.d (Sc. 3097, Civ. C.). <br />Lendcr's Name: <br />Lender's Address: <br />APPLICAI\T DECII\RATION <br />I hcr*yaffirmunder penalty of pcrjury onc of the following declarations: <br />Dernolition Permits-Asbcstos Notffication Fcdcral Rqulations (Title 40, Part6) <br />-Required <br />l-etter o f Notification <br />-l <br />cdiry that thc lidoal rcgulatiom r€garding abetos moval uc not applicablc to this prcjcl. <br />-l <br />cdiry that I havc ud this applic{tion aDd state that thc abovc itrformation is conct. I agre to smply with all City atrd County <br />ordimcB sd Statc llw rclating to building consruclio& sd hEcbyAthori4c rcprealative of this City od€punty to @tq upoo tlE <br />abovcmmtioncdprcpcnyforirepcrlnpurposgd') LVI - <br />Apptlcrnr or Ag6r s run rr *n 1 / I i 2 oZ ' <br />,.*n**.",or.r:, <br />- <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor /.Rat /c z>|7 ?Mra-/ <br />Gas-Underfloor <br />Building Sewer <br />Area/Storm 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 Flow <br />Pool Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitarv SewerlCao <br />Back Flow Device <br />Rough Plumbing <br />Fina! Gas Test <br />Meter Release lt ,l/,/^ <br />FINAL MIS/A/ru6(f <br />Notes, Remarks, Etc.tf <br />fzdu L_./) /tb*-,--*JaJ-o-u zt -h-?fur4-,/?r+,u*La 6*. <br />2-/- a--,/rr--'/ <br />-tfl ^/ ,{L.r"a/" ,, b*-r*. ,Zt, )- <br />-r4t n A,ale </u J/+J /'tlro b <br />Z Hrctres <br />la/./ <br />Carrier:. <br />_Expires: <br />to <br />.a-^ffi