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PLU M BI NG-I NSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNEN BUILDER DELCARATTON I hreby affm undtr poalty of pqjury that I m qmpt &om thc ConbactoB' Licm Lrw for thc fotlowingwn (Sc.7031.5 Buiaes urd Prcf6sion Code): Any City or County which rcquiro a pomit to @nstruc:t. altc. improvq danolish or npair uy struct@. prbr to its isumcc, also rcquirc thc epticmt for such p6mit to filc a signcd stdclmt that hc or drc b licoscd pwant to thc provisioE of the Cotrtrrclor's Liccnscd lrw (Chspt6 9. Comcncing whh Setion 7000 of Division 3 of thc Bsins md . Profsions Codc) or that hc or shc is cxcnpt th@from ud thc basb for thc alkgcd cxdption. Any violation of Setiotr 7031.5 b my applicmtforap6Eit3ubj6lsthc rpplicanttoacivilpmltyofnotmorcrhmfivchundrcddollu($500). _1. as ownef, ofthe property. or my employees with wages as their sole compensation. will do the work and the stnrcture is not intended or offered for sale (Sec.7044, Busincss and Professions Code: The Contraclor's License Law does not apply to an owner of the property who hlilds or improvcs theron" and who docs such work himself or hersclf or through his or her own employec. provided that such improvanants are not intendod oroffcrod for sale. If, howevcr. the building or improvement is sold within one )ear of complaion, tlrc Orvner Buildcr will have the hrdcn of proving ttra he or she did not build or improve the propoty for the purposcof sale). -1, as ownâ‚¬r of the propcrty, am exclusively contracting with licerucd contractom to construci ttrc projecr (Soc. 7044. Buiness and hofessbn Code: The Contractor's Liccnse Law does not spply to an owncr of property who builds or improves thereon, and who contracts for such projecis with a Contracto(s) liccnsod pursuant to the Contractor's Licensc law). -I am exempt under Section-. B. & P.C. for this reason. I)oto. WORKERS' COMPENSATION DECT.ARATION I hereby affirm under pcnalty of perjury one of the following declarations: _l have and will maintain a Certificate of Consent to Self-lnsurc for workers'compensation. as pnrvidcd for by Section .1700 of the I-abor Code, for the performance of the work for which the pcrrnit is issued. IV I have and will maintain workers' compcnsation insurance. as rcquired by Scction 3700 of the Labor Codc. for the po'formancc of G work for which this p,ermit is issued. My workers' compeosation irsurancc carricr and policy number arc: -l certi$, that in thc performance of the work for which this pcrmit is issued, I shall not cmploy any pemon in any manncr so as to become subject to the worters' compensation laws of Californiq and agrec that if I should bocomc subject to the workers' compensation provisions of Section 3700 of the Labor Code. I shall, forthwith comply with thosc provisions.. WARNING: Failure to secure workers'compensation coverage is unlawful, and shall subject an anploycr to criminal ponhies and dollars ($100.000). in addition to the cost of compensation. damages as provided for thecivil fines to one hundred thousand Section Labor Code. interest and attornery's 0c1 L DECI ^R/ATIONI hereby alnrrn under peoalty of perjury that I am liccnsod under povision of Chaptc 9 (commcncing with Section 7000) of Division 3 of the Buiness and Professions Code, and my licensc is in full force and cffect. Nurnber:t4 5 5 (?,1-, ,",., OQlnl/ 2l contrrctor: SO t,('.l - [on(k u..Kan f-nC,I W I hercby affrnn undr pcratty of pojury that th6e is a coctruction lcnding agmcy for thc pofonnilcc of the work for which this p6mit is issued (Se. 3097, Civ. C.). Lender's Name: I.crrtlcr''s Arkh css: APII.ICANLDECI.ABAUAN I hq*y aftrn undq pcnalty of pqjury orc of thc following dclrations: Demolition PmiteAsbctos Notification Fcdqal Rcgulatios (Tillc 40, PEr6) -Required Lrtta of Notificdiotr -t cqtiry that the fedsal regulatiom rcgading rbstos moval rc not applicsblc to this pDjE1. f,Eh cqriry thar I havc red this application and statc thrt thc sbovc infomation is corct. I agrE io comply with all Cfty md County ordimcs 6d Statc lr$ rchtiry to building condructioG ad hqcby authoriE rc?râ‚¬altstiva of this City md Couty to 6lq upon thc above mentioned property for Applicant or Agent Permitee nrme q c 'l-l UNDER GROUND Waste & Vent Water-Under floor Gas-Underfloor Buildinq Sewer Area/Storm Drain I nterceptor/ Clarifier TOP OUT Waste & Vent Water Pipinq Gas Piping Roof Drain Tub/Shower Test Rough Water Heater POOL/SPA P-trap/Drain Line Main Drain/Pool Piping Fill Line/Back FIow Pool Heater/Gas Line Miscellaneous Gas Service Water Service Lawn Sprinkler Sanitary Sewer/Cap Back Flow Device Rough Plumbins Final Gas Test Meter Release FINAL Notes, Remarks, Etc.