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PLUM BING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER, BT,ILDER, DELCARATION <br />I hcrcby atrrm undcr Fnrlty of pcrjury that I m cxctrDt ftom thc Contrrlos' Lkem taw for the following ren (Se.7031.5 <br />Business ard Profession Codc): Aoy City or County which requires 8 Ismit 1o @ostrucl, altc, imprcw. dcmlisbor rcpoir uy <br />smcrurc. prior to ils issrc, also rcquires thc 8ppliml for such pemil ao file s sigrcd ststemil th8t hc or dr is licnscd pusmt <br />to the prcvisions of thc Crntretor's LLrcnscd Law (Chaptq 9, Comrcing with Scclion 7000 of Division 3 of thc Busircss and <br />PrcfcsshnsCodc)orth8thcorshciscremptthcrcfromedthcbasisforthcatlcScdcxemption. Anyviol8tionofSstionTO3l.5byiny <br />applicsnt for I lrrmit subjccts thc spplicant lo a civil pcmlty of mt mrc thar fivc hundrcd dollus ($500). <br />_1. as owrrcr of the propcrty. or my employees with wagcs as their soh compcnsalion, will do the work and thc stnrture is not <br />intcrded or offered for salc (Soc.7044, Business and hofessions Code: Thc Contractor's License [aw docs not apply to an owncr of <br />thc propcrty who builds or improvcs thereon, and wln docs srch work hirnself or hcrsclf or through his or her own cmployces. <br />provided that such imprrrvcnrcnts arc not interded or offerd for salc. If. howevcr. the building or improverrnt is sold within one )tBr <br />of comphtion, the Owner Builder will have the burden of poving that he or shc did not buiH or inprove the profrrty for the purpose of <br />salc). <br />-1. <br />as owner of thc propcrty, am exclusivcly contracting with liccnsed contractors to construct thc proict (Scc. 7W, Business <br />and Pmfe.ssion Code: Thc Contractor's Licensc Law does not apply to an owner of propcrty who builds or improvcs thcreon, <br />and who contracts for such projects with a Contracto(s) licensed pursuant to thc Contractor's Liccnse kw). <br />-l <br />am cxempt undcr Section-, B. & P.C. for this reason. <br />l)atc: <br />WORKFRS' COMPENSATION <br />DECI ARATION <br />I hcreby affirm undcr pcnulty of pcrjury one of thc following dcclarations: <br />-l <br />have and will nraintain a Certificatc of Conscrrt to Sclf-lnsurc for workers' compensation, as providcd for by Scction 3700 of the <br />labor Codc. for thc Jrcrformarce of the work for which thc grcrmit is issucd. <br />_l havc and will maintain workers' compcnsation insurance. as requircd by Scclion 3700 of thc labor Gde. for thc performance of <br />thc work for which this prmit is issued. My workcrs' compcnsation insurancc carricr and policy nunrbcr arc: <br />sur;"r. ' ,ttlierf li,,;..tl Scrrrrccr, lrto <br />a <br />poricy lu-,,,"r: U^ lQOll'eEP t Expires:- Dl' lzozt <br />_l ccrtify that in thc pcrformancc of the work for which this pcrmit is issucd. I shall not cmploy any pcrson in any manncr <br />so as to become subjcct to the workers' com;rnsation laws of California. and agrce that if I should become subject to the <br />workcrs' compcnsation provisions of Section 3700 of thc L:bor Code. I stull, forrhwith comply wilh thosc provisions.. <br />WARNING: Failure to sccurc workers' comgrcnsation covcragc <br />civil fincs up to onc hundrcd thousand dollars ($100.000). in r <br />is unlawful. and shall subjcct an cmployer to criminal pcnaltics and <br />addition to lhe cosl of damagcs as provided for thc <br />Scction 3076 of thc Latnr Codc, intcrcst and attorncy's lbcs. <br />o,rc,' T ltil0tl t <br />I hcreby affirm undcr penalty of perjury that I am liccnscd Chapter 9 (comnrrrcing with Secrion 7000) of DiJision 3 <br />of thc Business and Professions Code, and my licensc is in full forcc and effcct. <br />Liccnse ctorr, | ]EA License <br />3 <br />Dare: ' TlHlUZt <br />W <br />I hcrcby affrm undcr Jrcnslty of lErjury that thcrc is a @nstruction hnding agcrcy for thc ;rcrfomcc of thc work for which this pcmil [s <br />issucd (Sa. 3097, Civ. C.). <br />Lrndcr's Namc: <br />Lcndcr's Addrcss: <br />AELICANI.DECI.dMTIgN <br />I hcrcby atrmundcr pcnrlty of lErjury onc of thc following delarations: <br />DcnDlition Pcrmits-Asbcslos Notification Rdcrol Rcgulations (Titlc 40, Pff6) <br />-Rcquircd <br />txttcr of Notifrcltk n <br />-l <br />ccrtify that the fcdcral rcgulations rcgarding asbestos rcnnval rc not rpplicabh to this pmj6t. <br />I ccrrify ttat I harc read this application and ststc that thc abovc informrtion is coret. I trg@ to comply with all Cityand Counry <br />ordinanccs and Statc kws rclating to building construction. ard hcrcby luthoriz rcprc*ntalircs of lhis City snd Countyto cntcr ulDn thc <br />atrovc nrcntioncd proprty for inslrcction <br />Applicant or Agenl <br />Permitee name <br />halo. O zlqluzt <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf Ioor <br />Buildinq Sewer <br />ArealStorm Drain <br />I nterceptor/ Clarif ier <br />TOP OUT I <br />Waste & Vent /lXgll,(.t:>t{rtHs 7 <br />Water Pipinq <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rouqh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />N/ain Drain/Pool Pipinq <br />Fill Line/Back FIow <br />Pool Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewer/Cap <br />Back Flow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release tt <br />FINAL vlt6l'/)t>w ,q <br />ltNotes, Remarks, Etc. <br />-) <br />a <br />0wner: <br />'ff| ;