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PLUMBING.INSPECTOR RECORD APPROVALS DATE ID/SIG COMMENTS OWNER BTM.DER DELCARATION I hercby 8fftrm undcr lEnalty of perjury that I m excrtpt tom ahe ContrrctoE Liccnse llw for lhe follovitrS rcawn (Scc.703l.l Busincss and Profcssion Code): Any City or County which rcquircs s pemil to mnstruct, alts, imprcve, &mlish or rcpair my structw, Firr to ils issure, rls rcquiEs the spplicsnt for such pcmit to fih s sigred slstcmnt thrt hc or dE h liccNd pursilt to thc provisions of the Contr.ctor's Liccn$d hw (Chspter 9, Clmrcing wilh Setion 7000 of Division 3 of the Business md PrcfcssionsCodc)orthathcorshcisexcmptth@fromsrdthebasisfortheslhgcdcxctrrplion. AnyviolationofsslbnT03l.5byany spplic8nt for s frcrmil subiEts the applicant to & civil pcnalty of not mrc thm livc hundrtd dollus ($500). _1. as owtrcr of thc prof,crty, or my cmployecs with wagcs as thcir solc compensation. will do the work ild thc stnrturc is not intcndcd or offercd for sale (Sec.7044, Business and Profcssions Code: Thc Contraclor's License Law does not apply lo an owner of thc propcrty who builds or improvcs thcreon, and who does such work hinrself or hcrsclf or through his or her own cmployccs. providcd that such impmvcnrcnts arc not intcndcd or offercd for salc. If. lmwerrcr, the building or imprcvcnrnt is sold within one )c&r of complction, the Owner Buildcr will have thc burden of proving that he or shc did not buiH or improvc the propctty for the purynse of salc). -1. 8s owner of the propcrty. am cxclusively contracting with licensed contraclom to construct thc project (Soc. 7W. Busirrcss and Prrofessbn Code: The Contractor's Liccnse IJw does not apply to an owncr of property who builds or improrrcs thereon, and who contracts for such projeas with a Contracto(s) licensed pursuant to the C,ontractor's License kw). -l am cxcmpt under Section-, B. & P.C. for this rcason. I )irlt TQSSEINTOMPINSIIDON DECI.A8AtrON I hcrcby rmrm undcr pcnalty of prjury ore of the following deleations: -l havc ad will mintsin I Cef,ificate of Consent to Sclf-lnsurc for workcrs' cotr{f,nstion, rs providcd for hy Scction 3700 of thc hhor Codc. for thc pcrfomncc of lhc work for which thc pcrmit is issucd. --.? l-f havc und will maintain workcrs' compcns.tion insumncc, as rcquircd by Scction 37OO of thc kbor Codc, for thc JErformncc of lhi work for which this lErmil is is$cd. My workm' @mpcnsslion insurrrcc cmicr and fnlicy numbcr trc: iP Gu^AD I Clrricr: Policy 0r- oG*? L _l ccrtify that in thc pcrformancc of thc work for which this prmit is issucd, I shall not cmploy any pcrson in any tnanncr so as to bcconrc subjcct to thc workcrs' compcnsation laws of California, and agrec that if I should bccomc subject to lhe workcrs' compcnsation provisions of Scction 3700 of thc l-abor Code, I shall, forthwith cornply with thone provisions.. WARNING: Failurc to sccurc workcrs'compcnsation coverage is unlawful. and shall subjccl an employer to crirninal pcnaltics and civil fincs up to onc hundred thousand dollars ($100.000). Scction 3076 of thc l-abor Code, interest and attorncy's fccs. in addition to the cost of comJrcnsation, damagcs as providcd for thc De.rat Oq-Oq-?-l DE'Cr ATIATTON I hereby affrm under ;rcnalty of perjury that I am licensed under provision of Chaptcr 9 (comnrcncing with Section 7000) of Division 3 of the Busincss and Professions Code, and my license is in full force and effect. Liccnsc Nunrbcr:7 s-t W I hcEby rffrm under Fmlry of perjury rhrt tlm is 8 @nstructbn bndirg agemy for thc Frfotlrc of lhc work for whkh this pcrmil ir issucd (Sc. 3097, Civ. C.). l.ender's Name: lrnder's Address: APPI ICANT DECI ARATION I hcrcby affirm under penalty of perjury one of the following declarations: Dernolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) -Required Letter of Notification _l ccrtify that thc fcdcralrcgulations rcgarding asbcstos rcmoval arc not applicablc to this projcct. I?".nify that I havc rcad this application and statc that the abovc informarion is corrcct. I agrce to comply with all Ciry ancl County ordinanccs and Statc Laws rclating to and hcreby authorizc reprcscntatives of this City and Counly to cntcr uJron thc above nrcnlioncd propcrty for inspcction Applicant or Agent IDernrilee nnnre AA o*", D 0.- O4-24 UNDER GROUND Waste & Vent Water-Under floor Gas-Underf loor Building Sewer ArealStorm Drain I nterceptor/ CIarif ier TOP OUT Waste & Vent Water Pipinq Gas Pipinq Roof Drain Tub/Shower Test Rouqh 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 lt Sanitary SewerlCao t"/z/?a frl"rrla Back FIow Device tl v \-/ I Rouqh Plumbinq Final Gas Test Meter Release tl Ir FINAL lol ttla J6f4) Etc.I Date:_C4-ofl*'Lt contracto r, ?tOTB-tt tr*c rattetbion)