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PLUMB!NG.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS <br />UNDER GROUND <br />Waste & Vent t*lf"a <br />Water-Under floor l/r \Jr <br />Gas-Underfloor <br />Buildinq Sewer <br />ArealStorm Drain <br />I nterceptor/ Cla rifier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test / <br />Rough Water Heater \ <br />POOL/SPA <br />P-tra plDrain Line <br />Main Drain/Pool Piping <br />Fill Line/Back FIow <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 Plumbins <br />Final Gas Test <br />Meter Release rI <br />FINAL L \'frA -Dt dY <br />t!aNotes, Remarks, Etc. <br />I hacby affum unda panalty of pcrjury that I m cxmpt ftom lhc Contracton' LiccN Law for thc following r*on (Se.7031.5 <br />Buins ard Prcfesion Codc): Any City or County which rcquiB I pqmit to coNlruct. altq. improvc. &molish or rcpair uy <br />structuq prior to its issumc. also rcquire thc applicut for such pqrnit to filc I signcd stdomt thst hc or $c b licqa€d pEusril <br />to thc fovisioN of thc Contrctor's Licmscd Law (Chapt6 9. Comming with Sction 7000 of Division 3 of thc BuineS md <br />PrcfBioN Codc) or that hc or shc is cxmpt thqcfrom od thc bBis for rhe allcgcd crmption. Any violalion of SElbn 7031.5 by any <br />applicantforapcmitsubjctsthc spplienttoacivilpcnaltyofnotmorcthsfivchundrcddoltua($500). <br />_1. as owner ofthe fopcrty, or my emplolrccs with wagcs as their sole compensation. will do the wort ard the srudurc b not <br />intcndcd or offered for sale (Scc.7044, Buiness and Professions Code: Thc C-ontracror's Liccnsc Law does not apply to an owner of <br />the property who hrilds or improves thcron, and who docs strch work himsclf or herself or through his or hcr own employccs. <br />provided that such imp,rovenrorts are not intended oroffued for sale. If. however, tlrc building or impnovanrcnt is sold within onc ),ear <br />of cornplaion, the Owner Builder will have the hrdcn ofproving thd lrc or she ditl not build or improve the propaty for the purpose of <br />salc). <br />-1. <br />ES owncr of the propcrty. am exclusively contracting with liccnscd contraclors to construct thc pnoject (Sec. 7044. Business <br />and hoftssbn Code: The Contractor's License Law does not applyto an owner of propcrty who builds or improves thcreon, <br />and who contracts for such projects with a Contracto(s) liccnsed pursuant to thc Contractor's Liceruc law). <br />-l <br />am exempt under Section-, B. & P.C. for this reason. <br />l)irlt' <br />WORKERS' COMPENSATION <br />DECLARATION <br />I hercby affirm undcr ponlty of perjury one of the following declarations: <br />have and will maintain a Certificate of Consent to Self-lnsure for workers' compcnsation. as provided for by Soction 3700 of the <br />Labor Code. for the performance of the rvork for rvhich the perrnil is issued. <br />91, <br />thc <br />have and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for the pcrfonnance of <br />work for which this permit is issued My workcrs' compemation ircurance carrier and policy number are: <br />Erct*+( Prnrsc,CL <br />Nunber. 76aoo 206/62// Expires:tf zo <br />_l ccrri$ that in the performance of the work for which this permit is issued, I shall not cmploy any pcrson in any manncr i <br />so as to become subject to the wortcrs'compensation laws of Cdifornia. and agree tha if I should become subjecr to the <br />workcrs' compensation provisions of Section 3700 of the l-abor Codc I shall. forthwith comply with thosc provisions.. <br />c <br />WARNING: Failure to sccure workers' compcnsation coverage is unlawful, and shall subject an onployer to criminal penahics and <br />civil fines up to one hundred thousand dollars ($100.000), in addition to the cost of compensation. damage as provided for the <br />Section 3076 of the Labor C.ode interest and attorrry's fe6. <br />I hercby affrm under pcnalty of perjury that I am licenscd 9 (commencing with Section 7000) of Division 3 <br />of the Business and Professions Code. and my liccnsc is in full force and effect. <br />W <br />I hmby alfim unda Falty of pcrjury that th@ b I couruction larding agacy for thc pcfome of thc wL for which this pamit b <br />ilsucd (Se. 3097, Civ. C.). <br />Lendcr's Name: <br />l cttilcr 's ,,\tlrlt css <br />APPLICANT DECLARATION <br />I hereby affrm under pcnalty of perjury one of the following declarations: <br />Dernolition Permits-Asbestos Notification Federal Regulations (Title 40. Part6) <br />_ Required Lctter of Notification <br />_l certi& that the lbderal regulations regarding asbcstos rernoval are not applicable to this project. <br />certify that have read this application and state that the above information is correct.agree to comply rvith all City and County <br />and State Laws relating to huilding construction.enler upon <br />above rnentioned property for inspection purposes. <br />or Agent <br />Pernrilee nanre <br />and hereby authorize represcnt at ives of this City and County to <br />u <br />the <br />t <br />,D <br />,i <br />CUrs B <br />€ltOfu <br />LicenseNumber: Ca ^€ <br />conrrecro r, E^, ;.**&l cr,-}***+n hn . <br />Signalure:_ <br />(print):c <br />Date: