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PLUMBING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby affirm under Fmlty of pcrjury that I m exempt frcm the ConrrctoE' Liccn$ kw for the following wn (Sc.7031.5 <br />Busincsr atd Profcssion Codc): Any City or County whkh rcquircs a permit lo onstnct, alts. imprcvq &mlish or rcpair my <br />structurc, Fior to its ksure, also rcquires thc applicmt for such Jmit lo [ile a signed stslemnt lhal lrc or shc is licensd t)lmant <br />to the prcvisions of thc Conrrctor's Licensd kw (Chaptcr 9. Collmrcing with Sstion 7(m of Division 3 of the 8usircs ud <br />Pmfcssiors Codc) or thsl he or shc is cxcmpt t|rcrcfrom and thc basis for the alleged cxcrplion. Any violatk n of SEtion 7031.5 by oy <br />applicanl for a pemit subjecls lhe aprlicrnt to 8 civil pcmlty of not mrc than five hundred dollss ($500). <br />_1, as owncr of the propcrty, or my cmployecs with wagcs as thcir solc compcnsalion. will do the work and thc structure is not <br />intendcd or offcrcd for salc (Scc.7044, Busincss and Professions Codc: The Contractor's License law does not apply to an owner of <br />the propcrty who builds or inproves thcrcon. and wln does srch work himself or hersclf or through his or her own employees, <br />providcd that such improvenrcnts are not intcndcd or offcred for sale. If. howcvcr, the building or improverncnt is sold within one year <br />of complction. the Owner Buildcr will have the burden of proving that trc or she did not build or irqnovc thc propcrty for thc purposc of <br />sah). <br />_1. as owncr of thc propcrty. am exclusivcly contracting with licenscd contractors to conslruct thc projcct (Scc. 7W. Busincss <br />and Pmtbssion Code: Thc Contractor's Liccnsc Law docs nol apply to an owner of property who builds or improves thcrcon. <br />and who contracls for such projccts with a Contr"rctor(s) liccnscd pursuant to thc Conlraclor's Liccnsc kw). <br />-lanrcxemptundcrScction-.B.&P'C.forthisrcason'I\.rra. <br />WORKEIIS' COM PENSATION <br />DECLARATION <br />I hcrcby affum under pnalty of pcrjury onc of the following dcclarations: <br />_lhavcalxlwill lnaintainuCcrtilicatcofConscnttoSclf-lnsurcforu'rlrkcrs'comJ^-nsation.as providcdtbrbyScction3T(X)ofthc <br />Labor Codc. for thc pcrttrrmancc of thc work filr which thc pcnttit is issucd. <br />4 nur"and witl maintain workers' conrpcnsation insurancc. as rcquircd hy.sccliorr 3700 of rhc Labor Codc. for rhc Jrcrlbrnnncc of <br />lhc work for which this pcrrnit is issucd. My w<lrkers' corrrpcnsatiorr insurancc carricr and policy nutttbcr arc: <br />L:of (auan4. =q^sw C,D <br />l <br />Policy k <br />_l ccrtify that in thc grcrformnncc of thc work for which this ;rermit is issucd. I shall not employ any person in any manncr <br />so as to bccomc subjcct to the workers' compcnsation laws of California, and agree that if I should bccome subjcct to lhc <br />workcrs' compcnsation provisions of Scction 3700 of thc labor Code, I shall, forthwith comply with thosc provisions.. <br />WARNING: Failurc to sccurc workcrs' comJrcnsation covcrage is unlawful, and shnll subjcct an crnploycr to criminal pcnaltics and <br />civil fines up to onc hundrcd thousand dollars (S100,m0), in addition to the cost of compcnsation. damages as providcd for the <br />Scction 3076 of thc Latxlr Codc, intcrcst and eltorrrcy's <br />NECLARATION <br />I herchy affirrn undcr pcnalty of prjury that I anr liccnscd undcr provision of Chaptcr 9 (cornrncncing with Scclion 7Un) of Division 3 <br />of thc Busincss and Profcssions Codc. and rny liccrtsc is in t'ull forcc ard cffcct. <br />Liccrrsc <br />(o 2,-\ <br />W <br />I hcrcby 8ffrm under Fndty of pcrjury thst thcrc is I @ostrution Lnding rgcrcy for the psfoffi of thc rcrk fot which this p6mil b <br />issucd (Se. 3097, Civ. C.). <br />Lcnder's Namc: <br />[,cndcr's Addrcss: <br />APPI ICANT NTCLAITATION <br />I hereby affrnr under penalty of perjury one of the following dcclarations: <br />Dcrnolition Permits-Asbcstos Notification Federal Regulations (Title 40. Part6) <br />-Required <br />l-etter of Notification <br />-l <br />ccrtify that the fcderal regulations regarding asbcstos rcnroval arc not applicablc to this proict. <br />_l ccrtify that I have rcad this Application and state that the abovc information is corrcct. I agrcc to comply with all City and County <br />ordinanccs and Statc l.aws relating to authorizc rcprescntativcs of this City and County to entcr upon the <br />abovc rrcntioncd propcrty for <br />Applicant or Agenl <br />Permilee name <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor ll <br />Gas-Underf loor nl,s/t-b <br />Buildinq Sewer I I <br />ArealStorm Drain <br />I nterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rouqh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />Main Drain/Pool Pipincr <br />Fill Line/Back Flow <br />Pool Heaterlcas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary SewerlCao <br />Back Flow Device <br />Rouqh Plumbinq <br />Final Gas Test <br />Meter Release tlt <br />FINAL rdBlzt <br />Notes, Remarks, Etc.I lrJ <br />I <br />Owner:- <br />Dete:_ <br />qqePLt}\a <br />( <br />_*," to/cs[a(