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PLUMBING-INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUTLDEN DELCARATION I hercby afftrm undcr lxnalty of Frjury th.i I m crcmpl ftom thc ConretoN' Liens bw for thc following rcen (Se.7031.5 BNincss atd Profcssion Code): Any City or County which rcquircs r pmit to mnstruct, rlter, imprcve, dc?mfish or rcpair rny structrc. prkr to its issume, rlso rcquircs the applicet for such pcrmit to file a signed slrtemnt thst hc or shc is liccnsed pusmt to thc provisions of thc Contractor'i Liccnsd llw (Chsplcr 9, Comrcing wilh Sction 7000 of Division 3 of thc Bushc$ rnd Ppfcssions Codc) or that hc or shc ii crcmpl thsrcfrom snd lhc basis for thc allcged eremption. Any violation of S6{ion 703 1.5 by any applicant for a pcmit subj@ls thc applic8nt to I civil pcBlly of rct mrc lho five hundrc{ dollus ($5fi)). _1. as owncr of the propcrty. or my cmployces with wagcs as their solc compcnsation. will do thc work and the stnrturc is not intendcd or offered for sale (Sec.7044. Busincss and Professions Code: Thc Contractor's Liccnsc l-aw does nol apply to an owner of thc propcrty who builds or improves thereort and who docs such work himsclf or herself or thmugh his or her own employees, provided thal such improvenrcnts sre not intcndcd or offcred for salc. If. howcrrcr. the building or inpnovenrnt is sold within one )aar of conqrletion, thc Owner Buildcr will harrc thc burdcn of proving thal hc or shc did not build or inqnove the profterty for the purynsc of sah). -1. as owner of thc property, am exclusively contracting with licensed contractors to construct thc project (Sec. 7W, Business and hrofessbn Code: Thc Contractor's Liccnse Law does not apply to &n owner of proprty who builds or improves thereon. and who contracts for such prof'cts with a Contracto(s) licenscd pursuant lo the Contractor's License taw). -l amexempl under B. & P.C. for this rcason. I):rlt'. ( )u lrer. WORKI. RS' COM PF'NSA TION DE'CLARATION I hcrcby affirm under penalty of pcrjury one of thc following declarations: -l have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation. as provided for by Section 37fi) of the Labor Code. for thc grcrformance of the work for which the prmit is issucd. have and will rnaintain workcrs'tnsurance, as by Scction 3700 of thc labor Code, for thc performancc of carrier ud plicy number are:ts Policy 3- _l ccrtify lhat in thc grcrformancc of thc work for which this permit is issucd. I shall not cmploy any pcrson in any manner so as to becomc subjcct to thc workers' compensation laws of California, and agrec that if I should bc"conrc subict to thc workcrs' compensation provisions of Section 3700 of the l-abor Code, I shall. forthwith comply with those provisions.. WARNING: Failurc to sccure workcrs' compcnsation covcragc is unlawful. and shall subjcct an ernployer to criminal pcnaltics and civil fines up to one hundrcd thousand dollars ($100.000). in addition lo thc cost of comFrcnsation, damagcs as providcd for the Scction '4":'*t6':y and attorncy's Ct I hcrcby affirnr undcr penalty of perjury that I am licensed under provision of Chapter 9 (commcncing with Section 7000) of Division 3 of thc Business and Professions Code, and my licensc is in full force ard effect. C6eLiccnse Date:-28- 2l W I hcrcby affEm urdcr pcmlty of perjury lh8t thcE is r @nstruction lcnding agcmy for rhe pqf()mre of ihc wqk for whhh this pcmit b issued (Ss. 3(x)7, Civ. C.). [,cndcr's Nanrc: I-cnder's Addrcss: API'I ICANI' DECLARATION I hcreby affrm undcr pcnalty of pcrjury one of the following declarations: Demolition Pcrmits-Ashstos Notification Federal Rcgulations (Title 40, Part6) -Required lrtter of Notification rcmoval are not applicable to this projc.ct. lhe above with all City and County and County to enter upon thc abovc mcntioned propcrty for Applicant or Agent and *r".8'76-2l UNDER GROUND Waste & Vent Water-Under floor Gas-Underf Ioor Building Sewer ArealStorm Drain I nterceptor/ Clarif ier TOP OUT Waste & Vent Water Piping Gas Pipinq Roof Drain Tub/Shower Test Rough Water Heater POOL/SPA P-trap/Drain Line Main Drain/Pool Pipinq Fill Line/Back Flow Pool Heaterlcas Line Miscellaneous Gas Service Water Service Lawn Sprinkler Sanitarv Sewer/Cap Back FIow Device Rouqh Plumbinq Final Gas Test Meter Release FINAL nldu N/,r(fi,n Remarks Etc. -License Number: - ? X.MAContraclor: Permitee name (print):_ t