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PLUMBI NG.INSPEGTOR RECORD -t <br />^APPROVALS DATE ID/SIG COMMENTS <br />UNDER GROUND <br />Waste & Vent z d <br />Water-Underfloor <br />Gas-Underfloor <br />Buildi Sewer <br />ArealStorm Drain <br />!Clarifier <br />TOP OUT <br />Waste & Vent <br />Water <br />Gas Pi <br />Roof Drain <br />Tub/Shower Test <br />Water Heater <br />POOUSPA <br />n Line <br />Main Drain/Pool Pipi <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />Misc <br />Gas Service <br />Water Service <br />Lawn nkler <br />Sa Sewe <br />Back Flow Device <br />Plumbin <br />Final Gas Test <br />Meter Release <br />FINAL <br />Notes, Remarks, Etc. <br />applicUion and statc <br />to and hereby <br />Declaration <br />I hocby affim uder paulty of pcrjury tha I m amp fm thc Cotretm' Limlc hv fc thc following mm (s.7031.5 Duitrs <br />ud Profcsim Codc): Any City tr Conty which rcquiro a pomit ro m3truc! rtt6, improvq doolish c rcpair my s6uchlrc, pritr to iEisrwe, also rtquiro thc applimt fq srch pcmit !o lilc 8 siSncd stamat ther hc o ihc is limscd pmuur o thc prcvisimi of rhc <br />Cmtretor's Ljfficd L8w (Chaptlr 9, Comcncing with Scrim 7000 of Division 3 of thc Buin6r od prcf*ioro Codc) u that hc or <br />ihc i8 cmPt thrcfrom md thc bsis fc$c allcgcd aarptim .Any violation of Scctim ?03t.5 by uy applimt fc apcrnit subjcrs rhc <br />applimt to a civil poalty of noa mffi rhm firc hu&cd <follu (S5OO). <br />It 6 oma of thc prcpcily, q my mployH with wagc u thcir solc mpcnsarim, witl do thc wst ud Oc sluctrc is mr intcn&d <br />or offqcd fc $lc ( Sa.7(N4, Buins ud Profqiou Codc: Thc Cont&ts't Licoc Law dq not apply to s omq of rhc prcpcrty <br />.who builds or imForo thm, ad who ds ruch wor* himclf or h6clf s thrcugh his c hcr om cmployccs, Fovidcd thar such <br />imPrcvmmls ec not inhdcd tr off@d fil salc. tf, how*cr, thc building or impovmcnt is sold withia'oi y; of cmplaion, 1rc <br />Omq-Builda will havc thc bur&n ofprcving rhat hc c shc nor build or improvc for thc purpocc ofsalc). <br />-I' <br />s our of thc Propqrty, m cxcluivcly onfrcting with licmred mrrcon to cotrstucr rhc prcjcr ( Sa. 70/14, Buincsi edPrcfqim Codc: Thc Cmtracld's Liffi Irw dG oot apply !o & omcr of prcpaty who buitas u iriprovc ucm , urd wtro <br />conts&E ftr such prcjcts with a Conractry(s) limcd puumt !o thc Conrreior'E Liw Lsw.). <br />_l arn excmpt under Section <br />Date: <br />I hereby aftirm undcr pcnalry ofperjury onc ofthe <br />-I <br />hrrc ud will mintain r Catificrrc of Cmat to Sclf-Imw fq wckcn' compasrtim, as proddcd fc by Setifl 37oO of thc <br />Labor Codc, fq thc psfme of thc wqt ftrwhid &c p€dnit i! isucd. <br />-I hre ud will mintain wqtm' onpers*io irmcq a ,cquircd by Sctim 37oo of thc Labor Co&, for thc Dcrf96e of 111cwct fc which thir pcmit ir isucd My watcn' cmporddl iDme uia ud policy nmba m: <br />Policy <br />(This section need not be complaed if the pcrnrit is for One hundred dollan ($loo1 or less) <br />_I certify that in the pcrformancc of the work for <br />bccame subjcct t(, thc workcrs ' compcnsation laws <br />which this is issucd, I shall not cmploy any in any manner so as to <br />of should bccome to the workerr' <br />compensation provisions of Scction 3700 Labor <br />WARIING: Failure to securg workers' cor4pensation <br />fincs up to one hundred thousand dollars ($(OO,o0Oy,in <br />the Labor Code, intcrcst and anorney's fccs. <br />is unlawful, and shall subjcct an <br />addition to the cost of compansuion, damages as providcd for the Scction 3076 of <br />Ihmbyafiimunda-,.,o,*i**",ffingin8withscctid7ooo)ofDivisim3of <br />thc Buins ud Prcfxim Codc, md my limc is in full fmc md cflct. <br />Datc: Contractor: <br />I hcty afEm u&r pqdty of p6jury thd *me of rhc wat fqwhich rhir psmit iri$ud (Scc. 3097, Civ. C.). <br />Lender's Name: <br />Lendcr's Addrcss: <br />Demolition Psrmits-Asbestos Noti fi cation Federal <br />_ Required Lener of Notification <br />APPLICATYT'S DECLARATION <br />Reguluions (Title 40, Part 6) <br />-l <br />certify that the fedod reguluions regarding asbcstos rqrnoval are not applicable to this project. <br />that is correct. I agree to comply with all City and County <br />above <br />of this City and County to entcr upon the <br />Applicant or <br />Permittee name <br />o <br />a <br />I 2 <br />L a ,? <br />P C foi'fiiiS'rcason <br />1