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I <br />PLU MBI NG.I NSPEGTOR RECORD I t' 1 <br />APPROVALS DATE ID/S!G.COMMENTS Ownfr-Bdlda D*lmtiil <br />t hmby aIEm uda Fmlty of pdjury thd I m acmpt fm thc Cmtrrcrm' Limsc Law ftr thc following rson (s@.7031.5 BuitrB! <br />md Profcim Codc): tuy City 6 Cmty which rrquiE . pGrnit to mstuct, dtd, improvc, dmolish or rcpair uy ttrusturc, pri6 to its <br />isume, also rcquiro thc rpplimt fo ruch pcmit to filc a signcd rlttqnat thr hc s shc is liccnscd pmuut io thc provilim of thc <br />Cmtnrrtr'! Ururd Ifl (Chrpt6 9, Cmcing rith S6tim ?000 of Dvirim 3 of thc Buin*s dd Ptofasimr Codc) or that hc u <br />3hc i! aanpt tharfioin md thc bsis fc thc rllcScd qdrptio .Any violtim of Setim 7031.5 by uy applimt fc a pcmit $bjsts thc <br />lpplist to s civil parrlty of nd m@ rhe fivc hmdrcd tlollm ($500). <br />_I, r oma of thc popctty, c my mploye with wag6 a dicir slc csrpeasrtion, sill do thc work md thc structw k not intm&d <br />or oficrcd fa illc ( 56.7044, Buin63 ed Prcfsim Codc: Thc Cobacic'i Lic63c Lsw dc not spply to a om6 of rhc propctty <br />who buildr c inprovs thacon" md who docr ruch work hinsclf tr hmclf c thrcugh his a ha om mployu, povided tha such <br />imprcmmt rc not iiladcd d offcrcd ftr sdc. lf, howcv6, thc builditr8 d improvmmt i! sold within onc ycar of complaion, thc <br />Owna-Builds will havc thc burda of provitrS that hc s lhc trot build o improve for thc putpoc ofsalc). <br />[], u mr of thc propcrty, m qclwivcly utracting with limccd mtretm to cmrtruct thc prcjcct ( Scc. 7044, Bsiner ed <br />Prcfcsrim Cods Thc Cmtrelo'! Licffi Law dm not apply to m oma of propcrry who builds c improva thcor , ud who <br />contracts for such projects with a Contracto(s) licensed pursuant to the License Law.). <br />\ <br />_l anr exempt under Section for this <br />Date: <br />I hereby aftirm underpeflalty of perjury one <br />_I harc od will mintdn r Cdtifietr of CMt to Sclf-Inlm fff wortd' cmpaBltim, s povidcd fc by Serion 3700 of rhc <br />L:bor Codc, fqthc p6fme of thc wdl fcwhich drc psmit ir irsucd. <br />Ihtwmdyillmaintrinwqhm'companruioninrwcc,u r€quircdbySdion3T00ofthcLabqCodc,for0rcpcrfomeofthc <br />wor* f6 which thir parnit ir ircucd. My wor*m' mpcruatim instme mia md policy nmbq uc: <br />Policy Number: Expircs: <br />(This section necd no, br.rnpl"rd if ,he pcrmit is for One hundred dollan {$lO0} or less) <br />_l certify that in the pcrformuce of the work for <br />became subject to the workers ' compensation laws <br />which this is issued, I in any manner so as to <br />that the workers' <br />compensation provisio,N of Soction 3700 of the Lsbor Codc, I <br />WARNING: Failure to secure workers' <br />fines up to one hun&ed thorsand dollars <br />compqlsation <br />($loo,ooo),in <br />unlawful, and an cmployer to criminal pcnalties and civil <br />addition to the cost of compc-nsation, damages as provided for the Scction 3076 of <br />the Labor Code, interest and attorney's fees. <br />@ <br />I hrcby affim udcr paslty of pcjury thrt t m limrcd udcr Fovirio of Chaptr 9 (mmacing with Scction 7000) of Divisio 3 of <br />thc Buins ud Prcfsim Codc, ud my limc is in full fG md cfr61. <br />Liccrue Class: License Numbcr <br />Date: Contractor: <br />@ <br />I hacDy rfEm m&rpa.lty of pajuy lhrt thc ir r cquruction lcodi4 garcy fc 0ro pqfmc of thc wdk fq which rhir pcnnir it <br />isucd (Sc. 3097, Civ. C.). <br />Lada'rNffi: <br />Lender's Ad&ess: <br />APPLICANT'S DECLARATION <br />Dcmolition Permits-Asbestos Notificuion Federal Regulations (Title 40, Part 6) <br />_ Rcquired l,ater of Notification <br />_I certi$ that the federal regulations regarding asbestos removal are not applicable to this project. <br />_ I certi$ that I have read that the a[ove information is correct. I agrce to comply with all City and County <br />above mcntioned <br />Applicant or agert sig. <br />Pcrminee namc (print): <br />and hereby authorize reprccntatives of this City County enter upon the <br />UNDER GROUND <br />Waste & Vent <br />Water-Underfloor <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 Pipeing <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOUSPA <br />P-trap/Drain Line <br />Main Drain/Pool Piping <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Misc <br />Gas Service t <br />Water Service ZIL r)L w tqfr <br />Lawn Sprinkler L'/ - <br />Sanitary SewerlCap <br />Back Flow Device <br />Rough Plumbing t rsr Bat <br />Final Gas Test -t-/ <br />Meter Release <br />FINAL <br />Notes, Remarks, Etc. <br />&. <br />a--:^-- <br />employ any <br />become <br />\