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PLUM BI NG.I NSPECTOR RECORD APPROVALS DATE !D/SIG.COMMENTS OWNER BUILDER I'EI,CARATION I h@by affum und6 pfialry of pcjury that I m q@pt from thc CoesdoB' Lic@ Law for thc followiag rcn (Sc.70J\5 Bwins and Prcfeion Codc): Any City or County which rcquira a pcmt ao orulrucl, altc, imprcvc, darclish or rpair my strucluq prior to its isumcc also rcquirc thc spplicet for such pcnnit to 6lc a signcd statmal thal hc or shc b licGcd pwanl to ahc provisioE of thc Contractor's Liccnscd Law (Chapt6 9, Comacing with Sction 7000 of Divisior 3 of thc Buire md PmfBsioN Codc) or that hc or shc is qcmpt th@&om ed thâ‚¬ b8sis for thc atlcScd smFion. Any violation of sEtbo 7031.5 by my applient for a pcrmit subjcts thc applicmt to a civil pcrulty of not rcE the five hudrcd dollm ($500). -1, as owncr of the propcrty, or my employees with wages as their sole compensation" will do thâ‚¬ work and the stnnure is not intcndod or offcred for sale (Sec.7044. Busincss and hofcssions Code: The Contraclor's Licensc [^aw does not apply to an owner of the propcrty who builds or improve thcron and who docs such work himself or hersclf or through his or hcr own employec, providd that such imp,rovanrcnts rc not intended oroffirod for sale. I[, howerrer. thc hrilding or improvenrcnt is soH within one ],tar of complaio& thc Ov.,ner Builder will have thc hrden of proving thd he or she did not build or irnpnovc the propoty for thc purposc of sale). _1, os owner of thc propcrty, am exclusively contracting with liccnsed contftrcton to conffuct thc project (Sec. 7044. Btsiness and kofcssbn Code: The Contractor's Licelse Law does not applyto an owncr of propcrty who builds or improvc thereon, and who contracls for such projds with a Contracto(s) licenscd puniuant to the Contractor's Licensc t aw). _l am under 8.,&P.C.rforthis.69 Owner: Kf'trtumOirpf,snr DECLARATION I hercby affrrm undcr poralty of pcrjury one of the following declarations: _l have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation. as provided for by Section 3700 of the labor Code. for thc perfonnance of the work for which the permit is issued. _l havc and will maintain workers' compensation insurance. as required by Section 3700 of the Labor Code. for the perfonnance of the work for which this pennit is issued. My workers' compensation insurance carrier and policy number are: Policy Number: Expires: _l cerri& that in the perforrnance of the work for which this permit is issued. I shall not ernploy any person in any manner so as to become subject to the workers'compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall, forrhwilh comply with those provisions.. WARNING: Frailure to sccure workers' compensation coverage is unlawful, and shall subject an cmployer to oiminal pcnalties and civil fines up to one hundred thousand dollars ($100.000), in addition to the cost of compensation, damages as provided for the Scction 3076 of the Labor Code, interest and attorney's DECI"ARATION I hcreby affrm under penalty of pcrjury that I am licensod undcr provision of Chapter 9 (commancing with Section 7000) of Division 3 of the Busincss and Profcssions Code, and my licersc is in full force and effect. Liccruc Class: Liccnsc Number: ('ontl':rclor' W I hwby aflm unda poulty of psjury thd th4 is a on*rucrion lading agcy for tbc pafow of thc mrt 6r wtfoh thL Fmn is iscd (Sc. 3097, Civ. C.). Lender's Name: [.cndcr's Ad&ess: APPLICAIT{T DECLARATION I her*y affirm under pendty of pcrjury one of thc following declarations: Demolition Permils-Asbcstos Notifrcation Federal Regulations (Title 40, Part6) -Roqu ired [rttcr o f l,lotificabn _l cotiS that the lederal rcgulations regarding asbestos rernoval are not applicable to this project. -l ccrri$r that I have read this application and state that the above information is conect. I with all City and County and County to mter upon theordinances and Statc Laws relating to building construclion, and above mentioned property for Applicant or Agent I'crnrilce nRnre UNDER GROUND Waste & Vent Water-Under floor Gas-Underfloor Buildinq Sewer Area/Storm Drain ! nterceptor/ Clarifier TOP OUT Waste & Vent Water Piping Gas Pipinq Roof Drain Tub/Shower Test Rouqh Water Heater POOL/SPA P-trap/Drain Line Main Drain/Pool Piping Fill Line/Back Flow Pool Heater/Gas Line Miscellaneous Gas Service Water Service Lawn Sprinkler tl Sanitary SewerlCao Qlnb, Back Flow Device I IU Rouqh Plumbinq Final Gas Test Meter Release ,IA FINAL td"h,tl INotes, Remarks, Etc. I Carricr:- orru, V ^?^7/ ,-"ffiqa)