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PLUMBING.INSPECTOR RECORD APPROVALS DATE ID/SIG COMMENTS OWNER BUITDER DET'ARATION I hmby allim unda pcralty of pcrjury thst I m amp fiom thc Contractos' Licos Law for thc following twn (Sc.7031.5 Buhcs and Profeion Codc): Any City or County which rcquirc a pcmit to co[ilruct. altq. improvq darclirh or npair my struciuq prior to its isuacc, also rcquis thâ‚¬ applicilt for such pcrmit to filc I signcd ctatmat tha hc or shc i licancd pwarl to thc provisiorc of thc Contr8ctor's Liccnscd hw (Chapt6 9. Commcing with Sction 7000 of Division 3 of thc Buins md Prcfessions Codc) or thst he or shc is qcmpt thscfrom ed thc basb for thc allcgcd qmption. Any violation of Sction 703 I .5 by my appliciltforspcrmitsubjclsthc spplicanttoacivilpaaltyofnotmorcthofivchundrcddollm($500). _1. as owner of the property. or my employees with wages as their sole compensation. rvilldo the work and the stnroure is not intended or offered for sale (Sec.7044, Business and hofessions Code: The Contractor's License Law does not apply to an orvner of the propo-ty who builds or improves thereon. and who does such work himself or herself or through his or hcr own employees. provided that such improvernents are not intendcvJ or ofFcred for sale. I[, howevcr. the building or improvement is sold within one year of complaion. the Or^.ner Builder will have the hrden of proving that he or she did not build or improve the property for thc purpose of sale). -1. as owner of the propfiy. am exclusively contracting with licensed contractors to construct the project (Sec. 7M4, Business and Profession Code: The Contractor's License Law does not apply to an o$'ner of propei-ly who builds or improves thcreon. and who contracts for such projects with a Contracto(s) licensed pursuant to the Contractor's License Law). -larnexemptunderSection-.B.&P.C.forthisreason' WORKERS' COMPENSATION DECLARATION I hereby affrrm under penalty of po'jury one of the following declarations: -l have and will maintain a Ccrtificate of Conscnt to Self-lnsure for workers' compcnsdiorL as providod for by Section 3700 of the Labor Code. for the pcrformance of the work for which the pernrit is issued. -l have and will maintain workerc' compcnsation insurance. as required by Section 3700 of the Labor Code. for the pcrformance of the work for which this pennit is issuod My workcrs' compcnsalion insurancc carricr and policy numh are: Carrier:-â‚¬*r,r-s hCf Policy Nu^bo,f l,4O I Cv7 I 1 Expires:ozlZoLZ -l certi& that in thc performance of the work for which this permit is issued, I shall not cmploy any person in any manner so as to become subjeci to the workers' compensation laws of California. and agree that if I should becomc subject to the I workâ‚¬rs' compensation provisions of Section 3700 of the Labor Code, I shall. forthwilh comply with thosc provisiors.. WARNING: Failure to secure workcrs' compensation coverage is subject an onployer togiminal penahies and civil I'rnes up to one hundred thousand dollars ($tn compensation. damages as provided for the Section 3076 of the Code. interest and attorney's I hereby affrm under penalty of pe{ury that I am licensed 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. -., License cla,.., \U? L License LOL*I I' L Darc:at/#/>t CONSTRUCTION LENDINC AGENCY I hoeby aflirrn under penalty of pqjury that thqe is a coffitruction lmding agmy for the pqfomocc of the work for which lhis pcmil is issucd (S*. 3097. Civ. C.). I.ender's Nanre: kndcr's Addrcss: APPLICANT NFCL\RATION I hqdryaftrTt under penahy of pcrjury one of thc following declarations: Dcmolition Pcrmits-Asbestos Notification Federal Rcaulations (Title 40, Part6) -Roquircd lctter of Notfficaion -l certi& that the fedcral regulations rcgarding asbestos rcmovalare not applicable to this projcd. e _l ccrti& that I have read this application and state the above information is correct. I agree to comply f this City with all City and County ordinances and State Laws relating to above mentioncd propcrty for Applicant or Agent Permitee neme and hereby authorize represcntatives o and Itt upon the UNDER GROUND Waste & Vent Water-Under floor Gas-Underfloor Building Sewer ArealStorm Drain I nterceptor/ Cla rifier TOP OUT Waste & Vent Water Piping *t*-?r EFrrf,r(r-- Gas Pipins Roof Drain Tub/Shower Test Rough Water Heater POOL/SPA P-trap/Drain Line Main Drain/Pool Pipinq Fill Line/Back Flow Pool Heater/Gas Line Miscellaneous Gas Service Water Service Lawn Sprinkler Sanitary SewerlCap Back FIow Device Rough Plumbing b4-z-t tua?$,L Final Gas Test Meter Release FINAL e1 -a-q,,1 S-- .?r.lz Notes, Remarks, Etc. il^t lJfiu-/, ,'t+r- ?-31-2 I Er-{-{P Ut( to the .*J d*