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PLUMBI NG.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARATION <br />I heby affm undc psalty of pgjury thd I u q@pt from thc CotrtretoB' Lic@ kw for the followirg !us! (Se.7031.5 <br />Buine aod Prcfcsion Codc); Any City or Cou!try which rcquiB I pqEil to @!slsct. alta. imprcvc damlbh or rq"r'uy, <br />structurc Fbr to itc isstmq slso rcquirB &c applicmt for such pmh to 6lc s sigrtd 3ldaErt thd hc or shc b licccd pwan <br />to thc provbioN of the Contsutor's Liccnscd law (Chaptq 9, Comming with S61ion 7000 of Division 3 of thc Bwinagmd <br />Prcf*ioro Co&) or that hr or sbc b qcmpt th@Eom md thc basis for thc dlcgcd umption. Any violrtioo of Scrion 7031.5 [v uy <br />rpplimt for 8 p6mit subjcts thc applimt to 8 civil pcmlty of rct rcrc thm fivc hudrcd dolla (3500). J <br />-1. <br />r omq of the propqty, or my mplole with wagc s thcir slc mmpcrualiorr will do thc work ard tlE sfildw is mt <br />inqdcd or offcrcd for slc (Se.7044. BuiB ed Prof*ioB Codc: Thc Codrsclor's Licw Law doc not pply to m om6 of <br />thc prcpsty who hril(b or irprorc tlpon ard who doa sh mtt hiNclf or hqElf or thrcugh his or ho om oploye, <br />providcd rhar such imFowrErl! rc mt htqdrd or offucd fur sh. Ii howffi. tlE ttriHiDg or irprwrra is pld withio m )a <br />of ompldion, thc Own6 BuiEc will harc thc burdgr of proving the hc or slrc dil mt buiH or impmrc tE Eopqty 6r thc Brpos of <br />slc). <br />-1, <br />re omc of thc pmpcty, u ocluivcly cornracling wilh licaBod cootretoB to @oilruci tlE Fojcl (Se. 7044. BEin6 <br />ard Pro&sion Codc: Ttc Contrator's Lic@c Law do€ ma apply to e om6 of prcpcrty who builds or impmv6 th6@D. <br />md who mntncts for such pmjct8 with I Codacto(s) licord punuarl to thc ConEstor's Liw Lrw). <br />-l <br />am exempt under Section-, B. & P.C. for this rcason. <br />WoRKERS, COMPENSATTON <br />DECI.ARATION <br />I hoeby afnrm under penalty of perjury one of the following declarations: <br />-l <br />have and will maintain a Ccrtificatc of Consent to Self-lnsure for work€rs' compensationt as providd for by Section 3700 of the <br />I-abor Codc, for the performance of the wort for which thc pcrmit is issued. <br />-l <br />have and will maintain workers' compcnsation insurance, as rcquired by Section <br />the work for which this permil is issued. My workers' compensation insurance carrier <br />3700 of the l-abor Codc. <br />are: <br />for the performance of <br />and policy <br />*,-rl-r,$r1-,c-uuL) <br />Policy <br />'l <br />(/ r.-z( <br />_l certiff that in the performance of thc work for which this permit is issucd, I shall not employ any person in any manner <br />so as to become subject to the workers' compersation laws of California, and agrec that if I should become subject to the <br />workers' compensation provisions of Seclion 3700 of the labor Code I shall, forthwith comply wilh those provisions.. <br />WARNING: I;ailure lo sccure workers'and <br />civil fines up to one hundred thousand the <br />attorney's fe6. <br />DECI.,ARATION <br />I hercby affrrm undcr penalty of perjury that I arn liccnsed under provision of Chaptcr 9 (comrncncing with Section 7000) of Division 3 <br />of thc Busincss and Professions Code. and my license is in full forcc and effect. <br />License <br />CONSTRUCTION LENDINC ACENCY <br />I hwby affirm und6 pcnalty of psjury that th6c is a @Btruction landiag agacy for the pqfomcc of thc rcrk for which this pqmit is <br />isuod (Se. 3097. Civ. C.). <br />kndq's Nmq <br />Lendcr's Address: <br />APPLICANT DECLARATION <br />I herclry aftinn undcr penalty of perjury one of the following declarations: <br />Dernolition Perrnits-Asbestos Notification Federal Regulations (Title 40. Part6) <br />-Rcquired <br />Ldter of Notification <br />--l certi$, that the fideral regulations regarding asbestos removal are not applicable to this project. <br />-l <br />certi& that I have read this and state that the above County <br />ordinances and State l-aws relating construclion.upon the <br />abovc mentioned <br />Applicant or Agent <br />Permitcrc <br />Z <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Building Sewer <br />Area/Storm Drain <br />I nterceptor/ CIa rifier <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 Pipinq <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service q-g-?A Dz-n* {.t <br />Lawn Sprinkler <br />Sanitarv SewerlCao <br />Back FIow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release IL <br />FINAL Ple4lu tl {n <br />Notes Etc. <br />Ltgr? tr2l, /4icenseNumbcr: . )qVr V <br />+conrracror, 6, ..?-, *,