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PLU M B! NG.I NSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI.,CARATION I hoeby alfm undo Fmlty of pcrjury that I m qmpt from thc Cortractots' Licw taw for thc following.ren (Sc.703lJ Buincs srd Prof*ion Codc): Any City or Courty which rcquirc a pcrnh to @fl*ruc( ahq, irnprovc danolish or npajr uy struclurq Fbr to its ismcc. slso rcquiB thc applimt for such pqmit to filc a signcd $armat thd hc or slE b licqEcd pl|Mt to thc provisioN of 0rc Contretor's Licascd Law (Chapt6 9, Comcncing with Setion 7000 of Divisioa 3 of thc BcitK md Prcfsioro Code) or rhat hâ‚¬ or shc b qcmpt th@from ud thc basis for thc allcgcd qmption. Any violation of Sction 7031.5 by uy applicutforEp6mitsubjctsthc rmlimttoscivilpcn8ltyofootmorcthelivchundrcddollm($500). -1, os owner ofthe propertyt or my employees with wages as their sole compensation. intended or ofFoed for sale (Sec.7044. Business and hofcsions Code: The Contraclor's License law does not apply to an owner of the propcrty who builds or imFovc tlreroru and wlrc docs such wort himsclf or hcrsclf or through his or her own employee. providd that such improvonents arc not intendod oroflAcd for sale. I[, howwer, thc building or improvcfiicnt is rcld within one ]rcar of complaion, the Ourncr Builder will have the hrden of proving tha he or she did not btrild or improve the popory for the purposc of sale). -I, 8s owner of the property, arn exclusively contracting with liccrsed contracton to construct the projct (Scc. 7044, Buiness and Pnoftssion Code: The Contractor's License Law docs not apply to an owner of property who builds or improvcs thereon, and who contracts for such projects with a Contractor(s) liccnsed pursuant to the Contractor's License law). _l am exempt B. & P.C. L I hereby alTirm undcr pcnalty of po'jury one of the following declarations: _l have and will maintain a Certilicate of Conscnt to Self-lnsure for workers'compcnsatioq as provided for by Soction 3700 of the l-abor Codc for the performance of the work for which the permit b issued. -l have and will maintain workers' compensation insurance, as required by Section 3700 of the l,abor Code, for the performance of the work for which this perrrit is issuod My workers' comporsation insurance carricr and policy numk are: Policy Number: Expires: _l certi& that in the pcrformance of the work for which this permit is issued, I shall not employ any person in any manner so uts to become subject to the workers'compensation laws of California, and agrec that if I should become subject to the workers' compensation provisions of Seoion 3700 of the Labor Code. I shall. forthwith comply with those provisions..J WARNING: Failure to secure workers' compensstion coverage is unlawful, and shall subjcct an and civil fines to one hundred thousand dollars ($100.000), in addition the Section I-abor Code,and attorney's \ Z L DECI,ARATTON I hereby affrm under penalty of pcrjury that I am licenscd under provision of Chaptcr 9 of the Business and Professions Code, and my license is in full force and effect. Soction 7000) of Division 3 Liceruc Class: License Numbcr: l)atc W I hacby afEm udq pauhy of pajury tba Um is a @nsrudbn loditrg !g@y for th. pafomc of thc rcrk br which thb pauil b issucd (Sc. 3097, Civ. C.). l.crttlcr's N;rtttc. Lendcr's Address: APPLICANT DECLARATION I hoebyaffirm undcr penalty of perjury one of the following declarations: Dcmolition Pcrmits-Ashcstos Notification Fedcral Regulations (Tille 40. Part6) - Requ ired Lettcr o f Notifi cltcn _l cotify that the federal regulations regarding asbcstos removal are not applicable to this projed. -l certi$, that I have read this application and state that the above information is correct. I all City and County ordinances and Statc laws relating to to cntcr above mcntioned propcrty for Applicant or Agent Pernritee nome \ Z Z thc UNDER GROUND Waste & Vent 1-Q,-21 **<olt- Water-Under floor Gas-Underfloor Buildinq Sewer ArealStorm Drain I nterceptor/ Cla rifier TOP OUT Waste & Vent ?4-ot .8, {Z Water Pipinq n-2-a w4 (t Gas Pipins Roof Drain t ^l tn t A Tub/Shower Test 4t t+tLl wMtxM.,ftb Rough 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 Sanitary Sewer/Cap Back Flow Device Rouqh Plumbins Final Gas Test Meter Release FINAL t^ln.r l'r..bn Rema Etc. + Carrier: Date:_ 17 Contractor:_ S^v/c lL>o e I