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PLUMBING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS Omq-Builda Dchntion <br />I lucby afiirm undcr perolty of pcjury that I am uemp fom thc Contnctor' Licce hw for thc following ramn (se7031.5 Buinu <br />rnd Profcsion Codc): Any City or Couty which rcquire s pqmir ro @Etruct, lltcr, improvc, dcmlilh or rcplir uy rtructurq Fior !o its <br />i$uncc, rbo rcquirB thc rppliqnt for 3uch psmit to filc a signcd stst@nt thst he or rlrc ir liered puEut to lhc prcvirioE of thc <br />Contnaor's Lierocd Lrw (Chlpts 9, Comcncing with Setion 7000 of Division 3 of thc Buinsr md Profesioru Codc) or thrt hc or <br />shc ir rempt thcrcfrom and thc brsis for thc rllcgcd qcmption .Any viohtion of Scaiotr 7031.5 by uy rpplienr for r p6mit 3ubjGct thc <br />appliont to s civil pcmlty ofnot morc tlm fivc hundrcd dolhB ($500). <br />_1, u orc of thc propoty, or my cmployc with wago as thcir rolc @mpcMtion, will do thc work ind ttrc 3trwtuc i! rct intcndcd <br />or offqcd for ldc ( 56.7044, Buin6t ud Profcalio6 Codc: Thc Contncbr'3 Liee Lw do6 mt rpply to e owr of thc prcpsty <br />who build! or improvB rhaotl ed who doa such work himrclf or hmclf or tkough hi3 or hs oM cmployccq providcd that ruch <br />improwmcils uc not intcndcd or offqcd for nlc. If, howcr, thc building or improvcment i! $ld within orc ya of omplaion, thc <br />Ow-Builds will havc the burdcn of proving dut hc or 3hc not build or improvc for thc purporc of slc). <br />_I, u oue of thc prop6ty, Em qcluivcly oamcting with li@Bcd @trtnclotr to @Etruct thr projel ( S€. 7044, Buin6! ud <br />Profsrion Codq Thc Contnctor's Lic4c lrw do6 not rpply to e omd of propqty who builds or imprcu rhcron , ud who <br />ontndr for ruch prcjerr with r Coilnsto(s) licascd pununr to thc Contraaor's Liccre Lrw.). <br />_I arn excmpt under Section +B. & P.C. for this reason. <br />Date: <br />WORKERS COMPENSATION DECLARATION <br />I hereby aftirm under penalty of perjury one of the following declaratioru: <br />I have and will maintain a Certificate of Consent to Self-Imure for workers' compensatior\ as provided for by Section 3700 of the <br />Lsbor Code, for the performancc of the work for wtrich the permit is issued. <br />_Ihaveandwillmintrinworlcm'mmpemtionirounncqu rcquircdbyScaion3T00ofthchborCodgforrhcpafonmeofthc <br />worh for which thir p6mit is isucd. My workcr' ompcnstiotr inrurue enicr ud policy numbc arc: <br />Policy Number: Expircs: <br />I Ghis section need not be completed if the permit is for One hundred dollars {$100} or less) <br />I <br />I <br />| _I certify that in the performancc of the work for which this permit is issued, I shall not employ any person in any manner so as to <br />I Uecame subject to the workers ' compensation laws of Californrq and agrec that if I should become subject to the workers' <br />I compensation provisions of Section 3700 of the Labor Codg I shall, forthwith comply with those provieions.. <br />WARNING: Frilurc to seuc worlo' ompcmtion owrgc is ulawful ud rhrll rubjer u cmplopr o aimiml pcnltic rnd civil <br />fm6 up to om hundrcd thousnd dolhE (3100,0@),in rddition to th€ cst of orDnstioq rhmga u provklcd for $c Sction 3076 of <br />thc hbor Codc, itrtqBt aod atomcy's fe. <br />W <br />I hrcby rfiirm unda pcmlty of pojury thrt I u lieu€d unds prcvirion of Chpc 9 (omcncing wirh S*rion 7000) of Divirion 3 of <br />thc Buinqs and Prcfcssioro Code, rnd my lierc is in full fore rnd cffct. <br />License Clacs: Liccnse Number <br />Date: Contnctor: <br />CONSTRUCTION LENDING AGBTCY <br />I hacby rfrum uda pcmhy of pajury thrr thm ir r corutruabn lcnding rgcncy for thc pcrforc of thc wk br wlrich thir pcmit ir <br />iuucd (Sa 3097, Civ. C.). <br />Iada'rNm: <br />knder's Address: <br />APPLICANT'S DDCLANATION <br />Demolition Psmiu-Asbesros Notification F€dcral RcguhtioN (Titlc 40, Prn 6) <br />_ Rcquircd Lrrtcr ofNotiriqtion <br />I enify thrt the federrl rcgulations rcgardiru Bb6to5 rcmoul uc not rpplieblc to this prcjct. <br />_ I @rtiry thEt I hsvc red this applietiotr strd rtEtc thrt thc sbow inforrotion ir @rccr. I agre to omply with rll City lnd County <br />ordiBnc6 tod Ststc l:s rehdng to building 6Etruc{io4 sod hqcby ruthorizc rcprutativs of thi! City snd Couty to mts upotr thc <br />ebovc mcntioncd propcrty for insprction purpose. <br />Applicant or agent <br />Permittee nsme (print): <br />I'lata' <br />UNDER GROUND <br />Waste & Vent <br />Water-Underfloor <br />Gas-Underfloor <br />Building Sewer <br />ArealStorm Drain <br />I nterceptor/ C larifier <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 <br />Water Service <br />Lawn Sprinkler <br />Sanitary SewerlCap <br />Back FIow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release <br />FINAL Ex ptf,{<tt) /t <br />Notes, Remarks, Etc. <br />)