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PLUMBING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER I'EI.CARATION <br />I hacby alfm und6 pqulty of pojury that I m qmp Gom thc Contr.clon' Licm t:w for thc following tEen (Sc:7031.5 . <br />Bwine ard hofsion C.ode): Asy City or Couty which roquire a pcmit to @rdrud, alts, improve <imlish or rpeir uy <br />structuq Fior to its iwcc, also rcquirc thc applicet for sch pqmit to filc a signcd staoot tha hc or Cp b licosod plmsn <br />to thc prcvisioB of thc Cotrtreror's Limscd Law (Chaptq 9. Comming with Scrion 7000 of Division 3 of thc Buins ud <br />ProfBsioG Codc) or thsa hc or shc is qmpt th6c&om 8td thc b6sis for tbc allcgcd soptioa Any violarioo of Sclbo 7031.5 by uy <br />8pplicut for r psrmit subjels thc applicsrt to . civil pmlty of not mrc tho fivc hundrcd dollm (5500). <br />-1, <br />ES owner of the propcrty. or my employecs with wages as their rcle compensation, will do ttrc work md thc stnrture is mt <br />intcndod or offcrcd for sale (Sec.7O44, Business and Profcssiors Code: The Contraclor's Licquc [aw does not eply to ur owner of <br />the property who builds or improve tlrcroru and who does zuch work himself or hcrsclf or through his or her own employees, <br />provided that such improvanrcots are not intended orofuod for sale. I[, howerrer, ttrc hlilding or impovqn€nt is sold within one ]rcar <br />of complaiou the Orvner Buildcr will have th€ hrdcn of proving ttra he or shc dkl not build or improve ttrc propcty for thc purposc of <br />salc). <br />-1, <br />os owner of the propcrty, am exclusively contracting with licensed contractom to construct the projec't (Sec. 7044, Business <br />and hofirssion Code: Thc Contractor's License Law does not spply to an owncr of propcrty who builds or improves thcreon, <br />and who contracts for such projccts with a Contracto(s) licemsod pursuant to the Contractor's Licensc l-aw). <br />-l <br />am exempt undcr Section-, B. & P.C. for this reason. <br />flo tr.' <br />WORKERS' COMPENSATION <br />DECLARATION <br />I hereby alTirm under penalty of perjury one of the following declarations: <br />-l <br />havc and will maintain a Ccrtificate of Consent to Self-lnsure for workers' compcnsation. as provided for by Section 3700 of the <br />Labor Code. for the pcrformance of the work for which the p,errnil is issued. <br />V, n^u"and will maintain workers' compensation insurance. as required by Section 3700 of the l-abor Code, for the pcrformance of <br />the work for which this permit is issued. My workers' compensation insurance carricr and policy numbcr are: <br />L/, Jca /rtjrrrlnlo.t CC <br />Policy <br />IA I cerrify that in the perforrnance of the work for which this permit is issued, I shall not employ any person in any manner,- <br />so as to become subject to the workers' compensation laws of California, and agree that if I should become subject to the <br />workers' compssation provisions of Section 3700 of the Labor Code. I shall. forthrvith comply with those provisions.. <br />I <br />WARNING: Failurc to sccure workers' compensation coverage is an anployer to crimrnal penalties and <br />civil fines up one thousand dollars ($100,000). in damaq as provided for thc <br />Section 3076 Codc, intcrest and attorney's fees. <br />I hereby aflirm under pcnalty ofperjury that I am licensod of Chaptcr 9 (commorcing with Section 7000) of Division 3 <br />of the Busincss and Profcssions Code. and my licerse is in full forcc urd effect. <br />License Nurnbc'r: <br />W <br />I hwby affm undc pcf,alty of psjury that thqe is a @nslructiotr Lndirg agdcy for thc pqfomce of the rcrh for which this pqrnit is <br />issued (Se. 3097. Civ. C.). <br />[ands's Nmc: <br />lrnder's Address: <br />APPLICAI{T DECII\]TATTON <br />I hcr'*Draffirrr under perulty of perjury one of the following declarations: <br />Demolition Pcrmits-Asbestos Notification Federal Regulations (Title 40, Part6) <br />-Required <br />lrtter of Notification <br />-l <br />ccrti$ that the federal regulations regarding asbestos rcmoval are not applicable to this project. <br />-l <br />certi& that I havc read this application and state all City and County <br />ordinances and State Laws relating to building <br />above mentioned property for inspcction <br />Applicant or Agcnt <br />Permilee <br />the <br />upon the <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor f ,/7-?1 fuc','/) <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/SPL <br />P-trapffi \frOat [) ,/ z,-w <br />NAdfn-praifr/Pool Pipinq ,/r' tl g.I ( <br />Fill Line/Back Flow <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 <br />Meter Release <br />FINAL lo-s -?rt t -se ttr. <br />Notes, Remarks, Etc. <br />xile .Expires: /- 3 f -LZ .