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PLUM BING.INSPECTOR RECORD APPROVALS DATE ID/SIG,COMMENTS OWNERBUILDERDELCARA'I'ION I. 3I hcrcby offirm undcr penslty of pcrjury that I m cxempt fiom lhc Contnctoa' LiccnE Law for thc following msn (Str)031.5 Busincas and Pmfcssioo Codc): Any City or County which rcquirB 8 lEmit to mnstrucl, !ltd, imprcrc, dcmlish or rtpair qry strucluE, prior to its issuarce, alrc rcquiG thc applicant for such ltmit to filc a signcd statemnt Ihar h. or shc is licmscd pumant to thc pmvisioN of the Contnctor's Lienrd Law (Ch.pts 9, Comenciog with Slclion 7fi)0 of Division 3 of thc Business and PmfcsionsCode)orthathcorslEisqcmptthercfmmandthcbssisforthc8llcgcdcxcmption. AnyviolationofSclionT03l.5byany applicantforapmitsubjctsthc applicanttoacivilpcmltyofmtmrcthanfivchurdrcddollus($5ffi). -1, as owner of the property, or my employees with wages as their sole compensation. will do thc work and the structure is rnt interded or offerd for sale (Sec.7044, Business and Professions Code: 'l'he Contractor's License Law does not apply lo an owner of the property wtro builds or improves ttrerenr\ ard wtn does such uork himself or herself or through his or her own employees, provided that such improvernents arc rnt intended orofu for sah. l[, trrworer, the building or improve]nent is sold within one yrar ofcompletioq thc Owner Builder will have the burden ofproving that hc or she did rnt huild or improve the propcrty for the purynseof sale). -1, as owner of the pmperty, am exclusively contracting with licensed contractom to construct thc project (Sec. 7M4, Business ard Proftssirn Code: '[he Contractor's License Law does not apply to an owner of property who huilds or improves lhereon, and who contracts for zuch projects with a Contracto(s) licensed pursuant to the Conlraclor's Licensc Law). -l am exempt under Section_, B. & P.C. for this reason. I ):r tc WORKER*S' COIT PENSA'I'ION DECLARATION I hereby alfirm under penalty of perjury one of the following declarations: -l have ard will maintain a Certificate of Consent to Self-lnsure for workers' conrpensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which the permit is issued. -l have and will maintain workers' compensation insurance, as required hy Section 3700 of the Lahor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier and policy number are: I'olicy Nunrber: l:xpires: -l certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as lo beconre subject to the workers'compensation laws of California, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Latnr Code, I shal!, forthwith cornply with those provisions.. WARNING: l;ailure to secure workers' compensation coverage is unlawful, and shall suhject an employer to crirninal Jrcnalties and civil fines up lo one hundred thousand dollars ($100,000), in addition to the cost of compensation, damages as provided for the Section 3076 of the Latnr Code, interest and attorney's fees. Appllcant:rrm nl'ct ArL{TloN I hereby affrm under penaltyof pcrjury that I am licensed under provision of Chapter 9 (commencing with Section 7000) of Division 3 of the Business ard Professions Code, and my license is in full force ard effect. License Number: fnnlronlnr. CONSTf, T'CTION LENDTNG AGTNCY I hcrcby affm urdcr pcmlty of prjury that tlre is a @mruc{ion lcnding s!ffiy ftrr lhc psfotlrrc of thc rcrk ft,r which lhi! pqmit ir isscd (Sc. 1097, Civ. C.). Lender's Name: Lender's Address: APPLICAN'I' DECLARATION I lrreby allinn under penalty of perjury one of the following declarations: Demolit ion Perrnits-Asbestos Notification lrederal Regulations ('l'itle 40, Part6) -Required Letter of Notification -l certify that the federalregulations regarding asbestos rentovalare not applicable to this pnrjcct. -l certify that I have read Ihis application ard state thnt the ah)ve inlirnnalion is coret. I agre lo comply with nll City nnd County ordinnnces and State Laws rclating to building construction, and herehy outJhrize reprcsentotives ofthis City and County to entcr upon the atEve nentiond pmpeny for inspcclion purlnses. Applicarrt or Agent l)att: l't'rlrrilre n:rrn(. (prirrt )' UNDER GROUND Waste & Vent Water-Under floor Gas-Underfloor Buildinq Sewer ArealStorm Drain I nterceptor/ Clarifier TOP OUT Waste & Vent Water Piping Gas Piping Roof Drain Tub/Shower Test Rough Water Heater POOL/SPA P-trap/Drain Line Main Drain/Pool Pipinq Fil! Line/Back Flow Pool Heater/Gas Line Miscellaneous Gas Service Water Service Lawn Sprinkler Sanitary Sewer/Cap Back Flow Device -.Rough Plumbing 6lt>'Jt? zi -/AnrDLtI P)) Fina! Gas Test I ,(It Meter Release FINAL Notes Etc.ID _ Owner: Date: