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PLUMBING.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCIIRATION <br />I hcrcby afftrm under penalty of Frjury th8t I m exempt ftom thc Conurctos' Liccns lrv for thc followint reNn (Scc.7031.5 <br />Busincss and hofession Codc): Any City or County which rcquircs a pcrmit to onstruct, alts, imprcvc, dcmlish or rcpair my <br />stncture, Itrbr to its issume. also requircs thc rpplicut for such pcmit to file a sigred slatemnt thrt he or dE is licensd pwsant <br />to the povisions of the Contmctor's Licensd ku (Chapts 9. Collmrcing wilh Sslioo 7000 of Division 3 of thc Busiress ild <br />PDfe$sions Codc) q thf,t hc q shc is exenpr thorfrcm atd thc bssis for rhc allcged crcmption. Any violstioo of Sefbn 703 I .5 by oy <br />applicant for r pcmit subjsrts thc applicant to s civil pcmlty of mt mrc thar fivc hundrcd dollus (S500). <br />-1. <br />as owncr of thc propcrty. or my cmployees with wagcs as thcir solc compcnsalion. <br />intcnded or offered for sale (Scr.7044, Busincss and Profcssions Code: Thc Contractor's Liccnse l-aw docs not apply to an owner of <br />thc propcrty who builds or improves thcrmn. and who docs zuch work hinuself or hcrsclf or through his or hcr own employecs. <br />provided thst such improraenrnts are not interxled or offered for salc. I[, however. thc building or inproverEnt is sold within orc ]tar <br />of complction, the Owncr Buildcr will have the burdcn of proving that he or she did not build or inprorc the propeny for thc purpose of <br />sale). <br />_1. as owncr ol'the propcrty. arn cxclusivcly contracting with liccnscd contraclors lo conslruct thc projcct (Scc. 7044. Busincss <br />and Profcssion Codc: Thc Contractor's Liccnsc Law docs not apply to an owncr of proJrcrty who builds or improves lhcrcon. <br />and who contracts for such projccts with a Contractor(s) liccnscd pursuant lo lhc Contractor's Licensc Law). <br />-lantcxclnplunderScction-.B.&P.C.l<lrthisrcason.Date: Owner: <br />WORKERS' COMPENSATION <br />DECI ,TRATION <br />I hcrcby affirrn under pcnalty of pcrjury one of thc following dcclarations: <br />-l <br />have and will maintain a Certifrcate of Consent to Self-lnsure for workers'compensation, as provided for bySection 3700 of the <br />labor Code. for the performancc of the work for which the permit is issued. <br />_l havc and will maintain workcrs' compensation insurance, as rcguircd by Sc.ction 3700 of the labor Code, for the lrcrformance of <br />thc work for which this pcrmit is issued. My workers' compensation insurarrcc carricr and plicy numbcr arc: <br />n-+D ) f& 5: ".?aY I +7< qZ TY <br />,r/?/rz-O Z7/72 .D <br />Policy <br />_l ccrtify that in thc pcrformancc of the work for which this permit is issued. I shall not employ any pcrson in any mantrcr <br />so as to bccornc subject to thc workers' compensation laws of California, and agree that if I should beconrc subject to the <br />workers' comgrcnsation provisions of Section 3700 of the L:bor Codc, I shall, forthwith comply with thosc provisions.. <br />WARNING: Failurc to liccurc workers'compcnsation coveragc is shull and <br />ill lhc <br />t <br />DECI ARATION I <br />I hcrcby allirm undcr pcnalty ol'pcrjury that I anr liccrrscd undcr provision of Chaptcr 9 (contnrcncing with Section 70001 of Division 3 <br />of thc Busincss and Profcssions Code. and nry liccnsc is in full forcc and cffcct. <br />-g.4 702t <br />Licensc <br />W <br />I hcrcby afftrm urdcr pemlty of pcdury th8t thm is r consrruction bndiry agercy for thc pcrforec of th€ rcrk for which this permfu is <br />issued (Scc. 3097, Civ. C.). <br />Lrndcr's Namc: <br />A PPLICANT DF'CLAITATION <br />I hcrcby uflirm undcr penalty of pcrjury one of thc following dcclarations: <br />Dcnmlition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40. Part6) <br />_Requircd [-ctter of Notification <br />certify that the fcdcral rcgulations rcgarding asbcstos rcmoval arc not applicable to this project. <br />ccrtify that I havc rcad this application and with all City and County^Uru)'"and Statc l-aws rclating to building <br />above rnentioncd propcrty for inspection <br />Applicant or Agent <br />Permitee nnme <br />and <br />Date: <br />j <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf loor <br />Building Sewer <br />ArealStorm Drain <br />I nterceptor/ CIarif ier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Pipino <br />Roof Drain <br />Tub/Shower Test <br />Rouoh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />It/ain Drain/Pool Pipinq <br />Fil! Line/Back Flow <br />Pool Heaterlcas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitarv SewerlCao <br />Back FIow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release A <br />F!NAL tdrcltt Ja <br />Etc. <br />I <br />-)) <br />an <br />x