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PLU M BING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNEN EUILDER DELCARATION <br />I hcreby affum under FBIty of pcdury thrt I m excnpt fiom rhc Contr8cm' Lkcre Lrw for thc following mn (Ss.7031.5 <br />Business od Profession Codc): Any City or County whbh rcquires s tEmir to onstrut. alt6, imprcve, dcmlish or rcp8ir uy <br />struchrc, prior to its issuore, slso requircs the applbut for srch pemit ao lih I si8rcd slrlcmnt lhat lE or slE b liccnsd plmstl <br />to thc prcvisbns of the Contnctor's Liccosed taw (Chsptcr 9, Colmming wilh Sction 7(m of Division 3 of ahc Busircss ud <br />Profe$ionsCodc)orthsthcorsheisererptthwfromardthcbasisforthcrlleScdexcmption. Anyviolationofs4lbnT03l,tbyuy <br />spplicmr for 8 pcmit subiEts thc spplicsrt to s civil pctrslty of mt mrc lhrn livc hundred do[rrs (S5m). <br />-1, <br />6 owncr of lhc prcpcny, or my cmplo)€s vith wrgcs s thcir slc ampensslion. will do lhe wut ard thc stnrhrc b ml <br />ircnded or ofrcrld for sle (Se.7044, Busircss ed Rofc$iotrs Codc: Thc Contactq's LLIE Lrw dcs ml ,pply lo m owffi of <br />thc FoIffiy who hrilds or inprcs tlEml and who dm sh wi* himslf or hcrclf or rhrcu8h his or her om erplolrccs, <br />prcvidcd that such imprcwrcnts m mt htcndcd or ofIeEd for sb. If, howffi. the buiEing or inprcrcmnt i! sH withh orc )sr <br />of orpletioo th OwH Buildcr will hsE tlE burdm of poving ths! hc q str di, mt hoild q inprcE ilE poFty fotr th ptleos of <br />sb). <br />D6 * o**, of U* prcpqty, m exclusircly @ntrrcting with lien$d @nlrrctos to @n*rucl llt ptoirr (56. IX4. BBircs <br />furd ProfcssimCldc:ThcContrctor'sLiccnst wdcsrctspplyiouowncrofprcpcrlywlrebuildsorimprcwslhcr@n, <br />and who @nlrrcts for such prcjctr with I Conts&to(s) li!rcn*d pursul to thc Contrctor's Licens [:v). <br />_l am B. & P.C. for this rcason. <br />11'( II{K IiRS' COII PITNS,\TI( )N <br />DECLARATION <br />I hcrcby alfirm undcr pcnalty of pcrjury one of thc following declarations: <br />-l <br />have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation, as provided for by Section 3700 of the <br />I-abor Code. for thc pcrformancc of thc work for which thc permit is issued. <br />-l <br />huvc and will maintain workcrs' compcnsation insurancc, &s rcquired by Scction 3700 of thc Labor Codc, for the pcrformance of <br />thc work for which this pcrmit is issucd. My workers' com;rcnsation insurancc carricr and policy numbcr erc: <br />Carrier: <br />Policv Number: Exoires: <br />l. <br />AS ccrtify that in the pcrformance of the work for which this permit is issued, I shall not employ any pcrson in any manncr <br />-so as to bcconr subjc"ct to the workcrs'compensation laws of California. and ngree thst if I should beconrc subject to thc <br />workers' compensation provisions of Section 370O of thc l-abor Code, I shall, forthwilh comply with those provisions.. <br />WARNING: Failure lo sccurc workcrs' comlrcnsation covcragc is unlawful. and shall subict an cmployer to criminal pcnaltics and <br />civil fincs up to onc hundrcd thousand dollars ($100,00O), in addition to the cost of compcnsation, damagcs as providcd for thc <br />Scction 3076 of thc l-abor Codc, intcrcst and allorncy's <br />I hcrcby affirm undcr pcnalty of perjury that I am liccnscd 9 (commencing with Section 7000) of Division 3 <br />of the Business and Professions Codc, and my licensc is in full forcc and effect. <br />Liccnse Class: License Number: <br />Conlractor: <br />W <br />I hcrcby aflirm undcr pnalty of pcrjury that thrc is a @nstruction knding rgcrcy lbr the pcrformncc of thc work for which this lEmit is <br />issucd (Ss. 1097, Civ. C.). <br />kndcr's Narrc: <br />Lcndcr's Addrcss: <br />APPLIC ANT DIICLARATION <br />I trcrcty aflirnr undcr pnalty of prjury onc of thc following dcclarutions: <br />Dcnrolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40, Parl6) <br />_Rcqu ircd lrtter of Notilication <br />-l <br />ccrtify that thc fcdcral rcgulations rcgarding asbestos rcmovalare nol applicablc to this project. <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf loor <br />Buildinq Sewer <br />ArealStorm Drain <br />I nterceptor/ Clarif ier <br />TOP OUT <br />Waste & Vent <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 />ltIain Drain/Pool Pipinq <br />Fill Line/Back Flow <br />Pool HeaterlGas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitarv SewerlCao <br />Back Flow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release <br />FINAL /0{ge{LCrS/rg@ *;lry <br />Notes, Remarks, Etc <br />Date:_