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PLUM BING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCANATION <br />I hcrcby affm undcr penslty of lErjury thsl I m cxcmpt frcm thc Conlracto$ Liensc lxw for lhc following rcssn (Sls.?031.5 | <br />Business and Prcfcssbn Codc): Any City or County which requircs s Frmit to @nstruct, 8lts. itrprcve. &mlirh or rcpoir uy <br />structurc, prhr to its issusnce. ds rcquircs thc applicut for such permit to fik ! signcd stqlemnt that he or shc is liensd pur;u8nt <br />to the provisions of thc Contrrcttr'B Liccnsd trw (Chspter 9. Comncing eith Scction 7fi)O of Division 3 of the Busincss and <br />Prcfessions Codc) or thst hc or shc is crcnpt thcEfrcm 8nd thc besis for thc slhged cxctrrption. Any violation of Scdbn 703 1.5 by any <br />applicrnl for a Jrcrmil subjsts thc rpplicant to a civil penalty of not mrc thu fivc hundred dollus ($500). <br />-1. <br />as owncr of the prof,crty. or my cmployecs with wagcs as their solc compensation. willdo thc work and thc stnrturc is ml <br />intendcd or offcred for sale (Scr.7044. Business and hofcssions Code: The Contraclor's License Law does not apply to an owner of <br />the propcrty who builds or improves thercon. ard who does such work himself or herself or thmugh his or her own cmployees. <br />providcd that such improvcnrnls are not intended or offercd for salc. If. however. the building or improverncnt is sold within one )rcar <br />of complction. the Orvner Buildcr will have the burden of proving thal hc or she did rnt build or inpmvc the propcrty for the purynsc of <br />salc). <br />-1. <br />as owner of the proprty. am exclusivcly contracting with licensed conlraclors to construct thc proict (Scc. 7W. Busincss <br />und hofession Codc: The Contractor's Liccnse Law docs nol apply to an owner of property who builds or improves thereon. <br />and who contracts for such projccts with a Contracto(s) liccnscd pursuant to thc Contractor's License kw). <br />-l <br />am excmpt under Section_, B. & P.C. for this rcason. <br />I )ttc: ( )rr nrr. <br />}YORKERS' CONIPENSATION <br />DECLARATION <br />I hcreby affirm undcr pcnalty of pcrjury onc of thc following dcclarations: <br />-l <br />have arxl will maintain a Ccrtificatc of Conscnt to Sclf-lnsure for workcrs' comlrcnsation. as providcd for by Scclion 37fi) of thc <br />l-:rbor Codc. for thc pcrformancc of thc work for which thc pcrmit is issucd. <br />-l <br />havc and will maintain workcrs'comJrcnsation insurance. as rcquircd by Scction 37fi) of thc Labor Codc. for thc Jrcrformance of <br />thc work for which this pcrmit is issucd. My workers'ton carricr policy numbcr arc:-t <br />Policy 2L <br />-l <br />ccrtify that in thc performarrce of thc work for which this pcrmit is issucd. I shall not cmploy any Frcrson in any manncr <br />so as to bccomc subjcct to thc workcrs' compensation laws of California. and agree that if I should become subject to thc <br />workers' comJrcnsation provisions of Section 3700 of thc [:bor Code. I shall. forthwith comply with thosc provisions.. <br />WARNING: Failurc to sccure workers' compcnsation covcrag,c is unlawful. and shall subjcct an employcr to criminal penaltics and <br />civil fines up to onc hundred thousand dollars ($100.000). in addition lo the cost of compensation. damages as provided for thc <br />Scction 3076 of Codc. inlcrcst and attorncy's fees. <br />I hcreby affirm under penalty of pcrjury that I am liccnscd under provision of Chaptcr 9 (commencing with Section 7000) of Division 3 <br />of thc Business and Professions Code. and my liccnse is in full force and effcct. <br />ralrLicensc <br />CONSTN.UCTTON LE{DTNG AGENCY <br />I hcrcby aflirm undcr penally of pcrjury that thcrc is a @nstnctbn bnding s8ercy for ftc Jxdomre of thc rcr* for whbh this frcmit b <br />issued (Se. 3097, Civ. C.). <br />knder's Name: <br />lrndcr's Address: <br />APPLTCANT DECLARATION <br />I lrrcby affinn undcr pcnalty of pcrjury onc of thc following dcclarations: <br />Dcrnolition Permits-Asheslos Nolification Fcdcral Regulations (Titlc 40. Part6) <br />-Rcquircd <br />Lcttcr of Notification <br />-l <br />certify that the federal regulations rcgarding asbeslos rcmovalare not applicablc to this proict. <br />-l <br />ccTl ify lhtrt I havc rcad this application ard statc thal lhc atnw informtion is corot. I agrc to @mJ,ly with all Cily and County <br />ordinanccs snd Stalc lrws rclsting to building consrudion. md hcrcby authorizc reprcrcntotives ofthis City and County to cntcr ulmn thc <br />abovc rncntioned proprty for insp.ction <br />Applicant or Agent <br />Permitee name <br />UNDER GROUND / <br />Waste & Vent Xfq/rc tt\t5( <br />Water-Under floor <br />Gas-Underf loor ttlh/tc{5b ffi' <br />Building Sewer <br />ArealStorm Drain <br />I nterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />lMain Drain/Pool Pipinq <br />Fil! Line/Back Flow <br />Pool Heaterlcas Line <br />Miscellaneous <br />Gas Service q/r^,s <br />Water Service U'4WV/il ffi <br />Lawn Sprinkler <br />Sanitary SewerlCap X/U/t,{^(#Back Flow Device <br />Rough Plumbing uie/tq 9u(1 <br />Final Gas Test <br />Meter Release //il ,-x) <br />FINAL "7/2/2.t u{alb t4u <br />Notes, Remarks, Etc <br />,l <br />Date:_ Applicant:_ <br />,rr",1l Contraclor: <br />-*,", 1/tl/l?