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- <br />PLUM BING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcby affum undr psulty of pcrjury thd I m qmpt ftom thc ContracloB' Licm trw for thc following ren (5€.7031.5 <br />BGines srd Profsion Co&): Any Chy or County which roquirB I p6mit to orstrucl, alt6, imprcvq danolish or rcpair my <br />structG prbr to its i$mcc ako rcquic thc agplicet for such p6mit to filc a signcd stdmot th.t hc or rlrc i9 licoscd pwant <br />to thr prcvisioE of thc Cotrtrstor's Licoscd taw (Chspt6 9, Comming with SEtion 700O of Division 3 of thc Busire od <br />Prcfeions Code) or that hc or shc is cx€mpt thqcfrom ud thc b6sis for thc sll€gcd cxmption. Any violatiotr of S61ion 7031.5 by my <br />applicant for . pcrrnit subjdts thc spplicant to a civil pcmhy of rct mrc lhe fivc hundrcd dollm ($500). <br />M* om6 of thc Fopqty. or my mployc with wag6 a thcir $lc ompcrsarion. will do thc w* ed tlE $rudr b mt <br />'intqrdcd or ollacd for sslc (Sc.7044. Buins md Profeioro Codc: Thc Contrsclor's Liffi Lrw do6 mt ry9ly to m ow of <br />the poperty who builds or improvs thcron. md who does zuch work himsclf or herself or through his or her own employcc, <br />provided that such improvanrcnts re not intendod ororFcrod for sah. lf, howarcr, thc building or improvemcot is sold within one )Gar <br />of completion, the Oryner Builder will have the burden of proviqg that he or she did not hrild or improve the propaty for the purposc of <br />sale). <br />-1. <br />as owner of the propcrty, am exclusivcly contracting with licenscd contractom to construc't the project (Sec. 7044. Business <br />ard koftssion Code: The Contractor's License Law does not apply to an owner of property who builds or improvcs thereon. <br />and who contracis for such projects with a Contracto(s) licarsed pursuant to the Contractor's License Law). <br />_l am exempt under B. & P.C. for this reason. <br />orr", /2rft'k) <br />I hereby aflinn under penalty of pcrjury one of the following <br />-l <br />have ard will maintain a Certificate of Consant to Self-lnsure for workers' compasation. as p,rovided for by Section 3700 of the <br />I-abor Code. for the performance of the work for which the perrnit is issued. <br />_l have and will maintain workers' comperuiation insurance. as required by Section 3700 of the Labor Code, for the performance of <br />the work for which this permit is issuod" My workers' compqrsalion insurance carier and policy number are: <br />a <br />JI <br />that in the performance of the work for which this permit is <br />of California. <br />issued. I shall not employ any person in any manner <br />and agree that if I should become subject to theas to become subject to the worketrs'cornpensation laws <br />workers' compensation provisions of Section 3700 of the l-abor Code I shall. forthwith comply wilh thosc provisions.. <br />WARNING: Failure to sccure workers' compensation coverage is unlarvful. and shall subject an onployer to criminal porahies and <br />civil fines up to one hundred thousand dollars ($100.000). in addition to the cost of comp€nsation, damages as provided for the <br />Section 3076 of the Labor Code, interest and attorney's <br />o*e, 12 ' /O' ?- O /e<.- <br />I hereby affrm under penalty of perjury that I am licenscd 9 (commencing with Section 7000) of Division 3 <br />of the Business and Professions Code. and my license is in full force and effect. <br />License Class: License Number: <br />l)al c <br />CONSTRUCTION LENDING AGENCY <br />I hmby alfim und6 paalty of pcrjury rhat th@ is a con$rucrion bnding agocy for thc pahtrmcc of thc wk for which this Fmit b <br />issucd (Sc. 3097. Civ. C.). <br />kndq's Namc: <br />lrnder's Address: <br />APPLICANT DEC I.,ARA'TION <br />I hereb), afiirm under penalty of perjury one of the follorving declarations: <br />Demolition Perrnits-Asbestos Notification l:ederal Rqgulations ('l'itle 40. Pan6) <br />-Required <br />Letter of Notification <br />_l certi& that the <br />GeituthatIha'e <br />fbderalregulations rcgarding asbcstos removal are not applicable to this project. <br />read this and state thal is correct. I agree to comply with all City and County <br />r represcntatives of this City and County to enter upon theand <br />above mentioned property <br />,,." /2 ,/o'ZoApplicant or Agent <br />purposes. <br />Permitee name tprin,l' b4Ll I f L <br />authorize <br />/)7 <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Building Sewer <br />Area/Storm Drain <br />I nterceptor/ Clarifier <br />TOP OUT <br />Waste & Vent I ,^ <br />Water Piping o t.Ll. u bo4trd,6 i6r <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOL/SPA t <br />P-trap/Drain Line l'L('u wt r{ <br />Main Drain/Pool Pipinq l'+'**hntb,6tr <br />Fill Line/Back Flow t'1..)r htvrt w^ <br />Pool Heater/Gas Line l, vt' ?l E+aeo(,$6n <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary SewerlCap <br />Back Flow Device <br />Rough Plumbing <br />Fina! Gas Test <br />Meter Release I I ir^ ,1 ?-e a <br />FINAL l0lNl31 arwup Sq tr <br />Notes, Remarks, Etc.tt <br />,^31-21- Feotrd4 il D..A fu/r*t lMa ,/ *ra/ 4/yA.l)-C-L A <br />\J <br />AI€Z <br />L <br />Contrnctor: <br />ordinances and State <br />, <br />,