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PLU M BI NG.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER I'ELCARATION I hcrcby aflim uodcr pcmlty of pGjury that I m cxempt fiom th. ContrrctoE' Liccn$ Lrw for thc followirg m$n (Ss.7011.5 Bwin6s and Pmf*ion Codc): Any City or County which rcquiffi s Imit to @nilrucl. ahd, imprcvq &mlish or ctEir af/ . structurc, prhr to its iesancc, alio rcquiffi thc epplicant for sch lEmit lo filc a si8rcd rtatercnt lhst hc or shâ‚¬ b liccned pumant to tlE pmvisions of thc Contrrctor'r Li@nsâ‚¬d L8w (Chapto 9, Commcrcing with Scction 7000 of Divisioo 3 of thc Bwines and PmfcsionsCode)orthathcorrhciscxcnrptthrcfromsndthcbosliforthcallcgcdcxcmption. AnyviolationofSctionT03l.5hyanyl applicant for s pcmit sbjcts thc applicanl to a civil pcmllyof mt mE than five hundrcd dollm ($5()0) . t _1. as ou'ner of the property. or my enlployees with u,ages as their sole compensation. willdo the u'ork and tlrc structure is nol interxle<l or offered for sate (Sec.7044, Ilusiness and Professions Code: 'l'he Contractor's l.icense Law does nol apply lo an owner of the property wln builds or irnproves thereon, and who does such work lrimself or hcrself or through his or her own empl<lyees, provided that such improvements Brc not intended or otTere<l for sale. ll, hou'ever. the building or improvement is sold within one year of completion. the Owner Builder will have the burden of proving tlurt he or she did nrt huild or improve the property for the pur;xrse of sale). _t. asownerof the property, amexctusivelycontracting with licensed contraclorslo construct the pmject (Sec. 7M4, Business arxl Prnllxsion Code: 't'he Corrtractor's l.icense Law does nol apply lo an o$'ner of property u'ho builds or intprovcs thereon, and who contracts for such projects with a Conlraclo(s) licensed pursuant lo the Contraclor's License [-au'). -lamexe]nptunderSection-,B'&P.C.ftlrthisreas<ln. Owner: DECLARATTON I hereby alTirm under penalty of perjury one of the following declarations: _l have and will maintain a Certificate of Consent to Self-lnsure for rvorkers' contpensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which the permit is issued. _l have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the perlormance of the work for which this permit is issued. My workers' compâ‚¬nsation insurance carrier and plicy number are: I'olicy I -- _l certify that in the perlirrmance of the work for which this permit is issued. I shall not employ any person in any manner so as to hecome subject to the workers' compensation laws of California, and agree that if I stnuld become suhject to the workers' cornpensation provisions of Section 3700 of the Latnr Code. I shall, forthwith comply with tlnse provisions.. b WARNINC: l;ailure to secure workers'compensation coverage is unlawful, and an employer to criminal penalties and civil fines up to one hundred thousand dollars (S100.000), in addition to of compensation,as provided for the Section 3076 of the Lahor Code, interest and attorney's I hereby affirm under penalty of perjury that I am licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Date:_-!]41 W I herchy afftrm under pcnsltyof pcrjury thar rhsc is a @nstruction lending agcrcy for the pcrformarcc of the work for which lhis Pemit ic issued (ss. 3097, Civ. C.). APPI ICANT DECI ARATION I haebyaffrmunder penalty of perjury one of the following declarations: Demolition Permils-Asbestos Notifrcation l;ederal Regulations ('l itle 40, Part6) -Required Lctter of Notification _l certify that the federal regulations regarding asbestos renmval are nol applicable to this project. _l certify that I have read this application and stale that the atrrve information is correct. I with all City and County ordinances and State Laws relating to and County to enter uJnn the above mentioned property for Appllcant or Agent Pernritee nanre arrl hereby P-/L- UNDER GROUND Waste & Vent Water-Under floor Gas-Underfloor Building Sewer Area/Storm Drain I nterceptor/ Cla rifie r TOP OUT Waste & Vent Water Pipinq Gas Pipinq Roof Drain Tub/Shower Test Rouqh Water Heater POOUSPA P-trap/Drain Line Main Drain/Pool Piping Fill Line/Back Flow Pool Heater/Gas Line Miscellaneous Gas Service Water Service Lawn Sprinkler Sanitarv Sewer/Cap Back FIow Device Rouqh Plumbinq Final Gas Test Meter Release tl FINAL lD/ta/n,rLO 31 Notes, Remarks, Etc I ,^ trt /rz /-, tH6Pe4 7 ATTU;lL avanfiW fzb{71) f \-,/ Expires: orr", 9-/2-4 (ti t en