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PLUM BING.INSPECTOR RECORD APPROVALS DATE !D/SIG.COMMENTS OWNEN BULDER DELCARATION I hcrcby allirm under pcnsty of perjury that I m cxctrlpt from thc Contruios' Licenw law for thc folbwing rcasn (Sc.7031.5 Busincss and Prcfcssion Codc): Any City or County which rcq[ires r lrmir to constrel, alter, improw, demli:h or rcpoir my Etructurc, prior to its issure, olso rcquires thc applicsnt for such permit to file a sigred staterent that he or slrc is liccnsd pmumt to thc provisions of the Contractor's Licenscd llw (Chapter 9, Clmmncing wi]h SEtion 7000 of Division 3 of the Business and Pmfessbns Codc) or that he or shc is crempt thcrcftom ard thc bsis for thc allegcd cxcmprion. Any violation of Scclion 7031.5 by any applicant for a pcmit subjsts rhe appliont to a civil pcnslty of mt mrc than five hurdtcd dollus ($5m). -1. as owncr of thc property. or my cmployees with wages as their solc compcnsation, will do thc work and the stnrturc is not intendcd or offcrcd for sale (Scc.7044, Busincss and hofcssions Codc: Thc Contractor's License Law docs not apply to an owncr of thc proSrcrty who builds or improvcs thcrcon, and who docs such work himself or hcrself or through his or her own employecs, providcd thal such improvenrnls are not interded or offcrod for sale. lf, howcver. thc building or inqrmvcrrcnt is sold within onc )car of conqllction. thc Owncr Buildcr will have thc burdcn of proving that hc or she did not build or in{rrorre thc property for thc purpose of salc). -1. as owncr of thc propcrty, anr cxclusivcly contracting with liccnscd conlractors lo construct thc projccl (Scc. 7W, Busincss and Profession Codc: The Contractor's Liccnse Law docs not apply to an owncr of propcrty who builds or irnprovcs thcrcon, and who contracls for such projccts with a Contractor(s) liccnscd pursuant to thc Contraclor's Liccrtsc l^rw). -IamexemptundcrSection-.B.&P.C.forthisrcason.I)ate: WoRKF'RS, COMPFNSATTON DECLARATION I hereby affirm undcr pcnalty of pcrjury one of the following dcclarations: -[ have ard will maintain a Certifrcatc of Conscnt to Sclf-lnsure for workers' compcnsation. as provided for by Section 3700 of ttrc I-abor Codc, for thc pcrformarrce of the work for whhh the permit is issued. -l havc and will maintain workcrs' compensation insurance, as rcquircd by Scction 3700 of thc labor Code. for thc pcrformance of the work for which this permit is issucd. My workers' compensation insurancc carrier and policy numbcr are: Policy */-- 3 A -Zz -l ccrtify that in thc Srcrformancc of the work for which this permit is issued, I shall not employ any person in any manncr so as to becomc subjcct to thc workcrs'compensalion laws of California, and agrcc that if I should becomc subject to thc workcrs' compcnsation provisions of Section 3700 of the labor Code. I shall, lbrthwith comply with thosc provisions.. WARNING: Failure to sercurc workcrs'compcnsation covcragc is and shall subject an cmployer to criminal Jrcnaltics and compensation. damages Bs providcd for thecivil fines up to onc hundrcd thousand dollarc ($1fi).000). in the cost of Scction 3076 of thc [:bor Codc, intcrcst and attorney's?7h I hercby affirrn undcr Jrcnalty of pcrjury thal I am liccnscd provision of Chaplcr 9 (comnrncing with Sc.ction 7000) of Division 3 of the Business and Professions Code. und my liccnsc is in full forcc and cff6t. 1 3b 7o3*Liccnsc Date: Nurnber: t W I hercby sfIrm urdtr penrlty of Frjury that tlse is s onslrErbn lading 88cmy for thc pcrforc of dE mrl for which this pqmit is issued (Scc. 3097, Civ. C.). l.endcr's Name: knder's Address: APPLICANT DECLARATION I hcrcby af irnr undcr pcnalty of pcrjury onc of the tbllowing dcclarations: Demolition Pcrrnits-Asbcstos Notitlcation Fcdcral Rcgulations (Titlc 40. Part6) _Rcquircd lrttcr of Notilication - -l ccrtify that thc federal rcgulations rcgarding &sbcstos rcmoval are not applicable to this projcrt.1 with all City and County and County lo cnler upon thc _l certify that I havc read this application and ordinances and Statc Laws relating to abovc mentioncd proJrcrty for Applicanl or Agenl Pernritee name I UNDER GROUND Waste & Vent Water-Under floor Gas-Underf loor Buildinq Sewer ArealStorm Drain I nterceptor/ Clarifier TOP OUT Waste & Vent Water Piping Gas Pipinq Roof Drain Tub/Shower Test Rouqh Water Heater POOL/SPA P-trap/Drain Line Main Drain/Pool Pipins Fill Line/Back FIow Pool Heaterlcas Line Miscellaneous Gas Service Water Service Lawn Sprinkler Sanitary SewerlCao Back FIow Device Rouqh Plumbinq Final Gas Test Meter Release ^--\ FINAL 16-79-Ll g-o(m I Notes, Remarks, Etc. Owner: O^rr&O , t-