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PLUMBI NG.INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER I'ET,CARATION <br />I h6cty affm und6 psulty of pcrjury thd I m ampt froE thc ContrrctoB' Licre trw for thc following rwn (Soc,70tl.5. <br />Buinas ud Prcf*ioo Codc): Any City or Couty which roquirc a pcrnit to sostruct, alt6, improvc, daolish or npair uy <br />structurc pdor to its isuuce also roquiro thc applirut for such p6mft ro filc a stDcd $ar@t thrt hc or Sc b limcd pman <br />to rhc pmvbioB of thc Coilretor'3 Lka:cd kw (Chaprs 9, Comming with Sclioo 7000 of Divirior 3 of thc Buim ud <br />Prcf*iouCodc)orthath.fishcbsmptthacfiomedthcb8bforthcdlcgcdaerprbu. AnyviolariorofsctiooT03l.5Wuy <br />applicant for a psmit subjcts thc applicut to a civil pcnalty of mt mrc thu fiv€ hundrd dollaE (3500). <br />-t, <br />s ow ofthc prcparn or my mplole with wage ro thcir $lc ompdstiolr will & thc wqt ad thc stsrdE is mt <br />irlodcd u offqrd for sb (Se.7044, BuiB ud Pr,oftssiou Codq Thc Cordrador's Li@ hw do6 mt apply lo u ow of <br />th€ Fopqry who hdi& or iryos tlsoq ad wto dm sh wtt hirelf or h@lf or thrcugh his or lr om mplo]6, <br />providrd tlEt sch imFowrds e mt iDtad.d or oftrod br eh. l[ how. thc hriEirU or itrprowHl fu $E wilhin onc ]a <br />of @rrylrb4 thc Om6 Builds will harc thc hrda of pmvilg ttd hc or $c did mt buiE or inpnorc the popaty br thc pupos of <br />sb). <br />-1. <br />a om6 of thc lmpcty, m aclwircly cootracting with licascd cotrEEloB to oEitruct thc trojd (Sc. 7(x4, BtuiB <br />ard Pmftsin Co&: Thc Coflrelor's Licmc [:w doc not eply to u ow[q of Fopcty who buil& or imprcu thmo. <br />od who sotset ftr such projc13 with 8 Contnclo(s) linscd psuan to rlE Codrsrlor's Lhqe try). <br />-l <br />m cxmDt und6 Sction- B. & P.C. for thb @r <br />0wner: <br />WORIGRS' COM'ENSANON <br />DECLARATION <br />I hereby affrrm under pcnalty of perjury one of the following declarations: <br />_l have and will maintain a Certilicatc of Consent to Sclf-lnsure for workers' compensation. as providd for by Section 3700 of the <br />Labor Code, for the po'formance of thc work for which the perrnit is issued. <br />_l have and will maintain workers' compensation insurance, as required by Section 3700 of thc labor Code. for the performance of <br />the work for which this pcrmit is issued My workers' compcnsation insurance carrier and policy number are: <br />a W.IVI {^;, b,-l l, ltzPolicy-6. C55 (-e - <br />_l ccrti& that in thc pcrformance of the work for which this permit is issued. I shall not employ any person in any manner <br />so as to become subject to the workcrs'compensation laws of California, and agree that if I should become subject to the <br />workers' comperuation provisions of Scction 3700 of the tabor Code I shall.with those provisions.. <br />WARNING: Failure to secure workers' compensation coverage is unlawful, and an and <br />civil fines up to one hundred thousand dollars ($100.000), in addition to thc of the <br />attorney's fees. <br />DECTI\RATTON . <br />I hereby affirm under paralty of pcrjury that I am liccnsod under provision of Chapter 9 (commcncing with Scction 7000) of Division 3 <br />of the Business and hofcssions Code, and my licensc is in full force and effect. , <br />t <br />License ,L <br />W <br />I hcfi aflm unda Fnlty of psjury thd th@ b I oonrudbn knding rgmy for thc pqforc of thc w* br uhi& thb pann i: <br />isucd (Sc. 3097, Civ. C.). <br />l-ender's Name: <br />Lcnder's Address: <br />APPLICANT DEC LATTATION <br />I hercby affirm under penalty of perjury one of the following declarations: <br />Dcmolition Permits-Asbcstos Notification Federal Regulations (Title 40. Part6) <br />-Required <br />Letter of Notification <br />\ I certifo that the <br />fl"*rfthat I have <br />federal regulations rcgarding asbestos reinoval are not applicable to this project. <br />read this application and state that the above <br />ordinanccs and Statc Laws relating to building construction, and the <br />above mentioned property for inspection <br />Applicant or Agent <br />Perrnitee nRme <br />* <br />is correct. I <br />1qt <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Building Sewer <br />ArealStorm Drain <br />I nterceptor/ Clarifier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Pipinq <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />Main Drain/Pool Piping <br />Fill Line/Back FIow <br />Pool Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewerlcap <br />Back Flow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release .-\ <br />FINAL lb4>a YDICl <br />Notes, Remarks, Etc. <br />.-E.> <br />Section <br />e <br />./t ,'\ B LiccnseNumber: ' 6t3 t <br />Ita /e t contrecto,,ba / -l ' <br />BF. :