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PLUMBI NG.INSPECTOR REGORD APPROVALS DATE ID/SIG GOMMENTS OWNER BUILDER DETrcARATION I hmby affrm undr penalty of pajury thar I m qmpt ftom the ContracloB' LiceN Law for the followiog ren (Sc.7031.5 Bwincs md Prof*ion Codc): Any City or County which requirc a pamit to @Etruct, altq, improvg danolish or npair ay . structure prior to its isuucq also rcquirc thc applicut for such pcnnit to filc a signcd stamot thal hc or slE b lic@sâ‚¬d pwuet llSdOe2yt@rntractor's Licqscd l.lw (Chapt6 9, Comocing with Setion 7000 of Division 3 of thc BNitrN ad- PrcfcsbreCo&)oithaTlErsheisqmptth@fromudthcbasisforthcallcgedumEion. AnyviolrtionofS*rion703l.5byuy spplimtfo.apcntritsubjetsthc applicettoacivilpâ‚¬naltyofnotmorcthefrvchundrcdclollm($500). -1, as owner of the property, or my employees with wages as their sole compensation, will do thework and the structure is not intended or offered for sale (Sec.7044, Business and Professions Code: The Contractor's Licerne Law does not apply to an owner of the property who builds or improves ther@n, and who does such work himself or herself or through his or her own employees. provided that such improvanants are not intended orofferod for sale. I(, howwer. the tnrilding or improvement is sold within one )rcar of complaion, the Ourner Builder will have the hrden ofp,roving ttra he or she did not build or improve the property for the purpose of sale). _1, as owner of the propoty, arn exclusively contracting with licensed contractors to construct the project (Sec. 7U4, Business and Profession Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a Contracto(s) licorsed pursuant to the Contractor's License Law). -l am exempt under Section-, B. & P.C. for this reason. Owner: WORIGRS' COMPENSATION DECLARATION I hereby affrrm under penalty of perjury one of the following declarations: -l have and will maintain a Certificate of Consent to Self-Insure for workâ‚¬rs' compcnsation, as provided for by Section 3700 of the Labor Code, for the pcrfonnance of the work for which the pennit is issued. _l have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permil is issued. My workers' compensation insurance carrier and policy number are: Carrier: l Policy _l certi$, that in the performance of the work for which this permit is issued. I shall not employ any person in any manner so as to become subject to the workers'compensation laws of California, and agree that if t should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I shall, forthwith comply with those provisions.. WARNING: Failurc to sue wolkm' compemation ovmge is unlawful, md shall subjet m mplolu to qiminal poultic md civil fmcs up to onc hmdrcd thomd dollm ($100,000), in additiotr to the cost of compereation, damaga c providcd for the Section 3076 of the Labor Code, interest and attorney's I hereby affrm under penalty of perjury that I am liccnsâ‚¬d under provision of Chapter 9 (commcncing with Section 7000) of Division 3 of the Business and hofcssions Code, and my license is in fuU force and effect. License tDJ oq 3 I ox",?-& f - [Lo*,) W I hwby affm uda pemlty of pdjury that th6e is a @ns(ruction lmding sgocy for thc psfomce of thc work for which this pqnit is issued (Sc. 3097, Civ. C.). tcnds's Nme: - Lender's Address: APPLICANT DECLARATION I herdry affirm under penalty of perjury one of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) -Required Letter of Notification -l cqtiry that thc federal regulatioro rcgading 6b6tos rmoval de not applicable to this prcject. _l cgtiry that I have red this application od statc that thc above infomtion is cored. I agr@ to comply wilh all City ud County ordinancB ild State laws relating to building coNtructiorl 8nd hqcby authorize reprMtative of this City od Counly to @t6 upon thc above mentioned property for inspection Applicant or Agent Permitee nRme ,,,., &&f -80&/ UNDER GROUND I / ,-r Waste & Vent 7-?zz(((-u* Water-Under floor y'ze -: Gas-Underfloor ,te+/(&-z 7 Building Sewer Area/Storm Drain I nterceptor/ Cla rifier TOP OUT Waste & Vent Water Piping Gas Piping Roof Drain Tub/Shower Test Rouqh Water Heater POOL/SPA P-trap/Drain Line Main Drain/Pool Pipinq Fill Line/Back FIow Pool Heater/Gas Line Miscellaneous Gas Service Water Service Lawn Sprinkler Sanitary SewerlCap Back FIow Device Rough Plumbing I ;,L5/4 {Lr)) Final Gas Test Meter Release FINAL c -?p:-,Ll ItlJ-t 9 d e 0a7 -1'l Notes, Remarks, Etc. I orrur2'lf '{hd