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PLUM BING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hercby alfirm under penslty of pcrjury that I m exempt frcm the ContncloE' Liccns tiw for the following rc&sn (Stc.7031.5 <br />Busincss and Profession C(dc): Any Cily or County which rcquircs I ]Emit to snstnrct. ahs. imlrcrc. &mlish or rcpair uy <br />strucluE. Fbr to ils issuare. also rcquires the spplicul for such pemit to file I signcd slarcmnl lhrt lE or she ir liccr$d puNail <br />lo thc pmvisions of the Contrrclor's Liensd Lrw (Chaplcr 9, Commercing with Sction 7000 of Division 3 of the Busincss snd <br />ProfcssbnsCodc)orthathctrshciscxcmprthcrcfmmandlhcbrsisforthcalhgcdcxcmption. AnyviolationofSc{:lkrn7O.1l.5by8ny <br />rpplicsnt for s pcmit subj€ts the spplicant to 8 civil peulty of mt mrc thatr five hundrcd dollus ($500). <br />-1. <br />as owner of the property. or my employees with wages as thcir sole compensation. will do the work and lhc slructure is not <br />intendcd or offered for salc (Scc.7044. Business and hofessions Code: Thc Contraclor's Liccnsc l-aw docs not spply lo an owner of <br />the property wln builds or inpoves thcreon. and who dnes such work himself or hersclf or through his or hcr own employees. <br />provided that such improvenrnts arc not intended or offered for salc. lf. howcvcr. thc tuilding or impmvenrnt is sold within one )€ar <br />of comphtion. thc Owner Buildcr will havc thc burdcn of proving thot he or shc did not build or improve thc proF,cny for thc purpsc of <br />salc). <br />-1. <br />as owncr of the propcrty. am exclusively contracting with licensed conlraclors lo construct lhc projcct (Scc. 7014. Busincss <br />and hofession Codc: The Contractor's Liccnse L,aw docs not apply to an owner of propcrty who builds or irttprovcs thcrcon. <br />and who contracts for such projccts with a Contractor(s) liccnscd pursuanl lo the Contractor's Licensc L:w). <br />-l <br />am exenrpt under &lir r <br />u,*, S'2 -2i lL <br />DECLARATION <br />I hcrcby alllrrn undcr penalty of perjury onc of thc following dcclarations: <br />_l have and will maintain a Certificatc of Conscnt to Sclf-lnsure lilr u'orkcrs' com;rcnsation. as provided frrr by Scction 37fi) of thc <br />I-abor Codc. for the pcrfornuncc of the work for which thc yrcrnrit is issued. <br />-l <br />have and will maintain workers' compensalion insurance. as required by Section 37fi) of thc Luhor Code. for thc pcrlirrttunce of <br />thc work for which this Jrcrmit is issucd. My workcrs' compcnsation insurancc carricr aml plicy numhcr arc: <br />Carricr: <br />Policv Numbcr: Exnires: <br />-l <br />certify thal in the perforrnance of lhe work for which this pcrmit is issued. I shall not cnrploy any pcrson in any nurnncr <br />so as to bccomc subjcct to thc workcrs'conrpcnsation laws of California. nnd ngrcc that if I should hccornc suhict to thc <br />workcrs' cornlrcnsation provisions of Scction 3700 of thc [:tnr Codc. I shall. forthwith cornply with thosc provisions.. <br />WARNING: Fuilure to sccurc workcrs' conlpcnsatiot'r covcragc is unlawful. and shall subjcct an cnrploycr lo crinrinal Jrcnaltics and <br />civil fines up lo onc hundrcd thousand dollars ($100.000t. in addition to lhc cosl of conrpcnsalion. damagcs as providcd for the <br />Seclion 3076 of the Latnr Codc. intcrest and atlorncy's <br />Dil",5-?- zpllf <br />IIECLARA'I'ION <br />I hcrchy allirrrr unclcr pcnalty of pcrjury Ihat I arn liccrrscd urxler provision ot'Chapter 9 ( cornnrncirrg u'ith Sccl iort 7UX)) ol' I )ivision 3 <br />of thc Busincss arrd Pr<ll'cssiorts Codc. artd nry liccnsc is in full firrce arxlcl'l'cct. <br />Liccnsc Class: Liccnsc Numbcr: <br />C(INS'tRUC'TI(IN I,ENDIN(] A(:ENCY <br />I hcrchy rffir[r uldcr pcMhyofpcrjury lhnl lhcrc is a constructi<n lcnding agcncy for thc pcrforn[ncc ofthc rvork lirr rvhich this lurnit is <br />issucd (Scc. .1097. Civ. C.). <br />hndcr's Nanr: <br />krtdcr's Ad<lrcss: <br />APPLICANT DECLA R,ATION <br />I Myaflirmunder penalty of perjury one of the following declarations: <br />Demolition Permits-Asbestos Notification Federal Regulations (Tille 40. Part6) <br />-Required <br />l-etter of Notilication <br />with al! City and County <br />and County lo enler upon the <br />abovc mentioncd property for IbApplicanl or Agenl <br />Pernrilee nBnre <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf loor <br />Building Sewer <br />ArealStorm Drain <br />I nterceptor/ C larif ier <br />TOP OUT <br />Waste & Vent <br />Water Piping <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rouqh Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />Main Drain/Pool Pipinq <br />Fil! Line/Back Flow <br />Pool Heater/Gas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary SewerlCap <br />Back Flow Device <br />Rough Plumbing <br />Fina! Gas Test <br />Meter Release <br />FINAL /0 //-7 LCb/L /t%zr>W <br />Notes, Remarks, Etc. <br />-I <br />Conlraclor:_