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PLUMBING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS ()WNI:R BUII-DER I)EI,CARATI()N <br />I hcrcby nllirm undcr pcn{hy of Frjury that I an excfipt lionr thc (bnlracbs' l-iccnsc law for thc folhwing rcasotr (SN.7l).11.5 <br />Busilcss nftl l,rofcssion Codc): Any City or County which rcquircs n Jrrmit lo conslrucl. altcr. irnprovc. dcmolish or rcplit my <br />struclurc. prior to its issuancc. illso rcquircs lhc trpplicilnl lbr such lErmit h filc a si8lcd shlcmnt lhal hc or shc is liccnscd putsudnt <br />t) thc provisiuls of lhc Contrnckrr's Liccnsd liw (Chaplcr 9. Cotrnncming wilh Scclion 7(Xn of Divisi(ln 3 of lhc Busirrcss and <br />ProfcssionsCodc)orthathcorshciscxcmptlhcrcfromandthchusislirrlhcalhgcdcxctrrpti(rn. Anyvk)lalionofscclionT0.ll.5hyany <br />applicantli)rilFrmitsubjccrsthc applicantkrncivilpcnaltyoftrottrDrclhdnlirchundrcddollars(S5(x)). <br />_1. !s owncr of the proFrrly. or my cllployccs wilh wagcs as thcir $lc conucnsnl knr. will do thc wotk afrl llrc slrr1rc is not <br />intcndcd orollcrcdforslc(SN.7()44.BusinessdldPnrfcssionsCo(lc:lhcConlr{clor'sl-iccnscLowdocsnotrpplyloanowncrof <br />thcpmFny wh)huildsorimpmvcsthcNn.andwhodocssuchur)*hilrsclforhcrsclforlhroughhisorhc.owlcmpktyccs. <br />providcd lhill su(h hnpm\rtrrnls m N)t inlcfllcd or olTcrc{ for sh. ll. lx)wc\ci thc huik ing or iryrerciltnl is skl wilhin onc }ear <br />ofcotnpldbn. thc Owncr Buiklcr will harc thc hur(hn of pmving that hc or shc di<, not huiu ot hqro\t lhc pnFdy lbr lhc purFr* of <br />$rlc). <br />_1. as owncr ol'thc propcrty. atn cxclusively conlrilclilrg with liccttsctl conlractors ttt cottslnlcl lhc projcct (.Scc. 7044, Busincss <br />and PmlgishrrCodc:ThcContractor'sLicerrscl-awtltrcsnotapplyt()un()rvncrofpropcrlywhobuilds()ritllprovesthcrcon. <br />and who conlracts for such projccts with a Conlraclor(s) liccnsctl pursuant lo lltc Conlractor's Liccnsc l-aw). <br />_l ant cxcllpl undcr Scclion-. B. & P.C. lor lhis rcasolt. <br />Date:_( )rvnt r: <br />WORKERS' COMPENSATION <br />DECI ARATION <br />I hercby affirm undcr penalty of perjury one of thc following declarations: <br />_lhavclndwill lrraintainaCcflificateofConscrrttoScll-lnsurctbrworkcrs'corttpcttsalion.ils providcdtirrbyScclioltST(X)ttfthc <br />Lahor Crxlc. lorthc pcrfrrrrruncc of lhc work lirr which thc pcrrnit is issucd. <br />_l havc 1nd rvill maintain workcrs'cotrrpcnsalioll insurancc. us rcquircd byScclion.lT(X)ol'thc Lahtr(trdc. lbrthc pcrlorlttuttccof <br />lhc work lor u'hich this pcrntit is issucrl. My workcrs' compcnsalion insuritncc carricr antl Jxrlicy nunltrcr arc: <br />Policy <br />_l certify that in thc performance of the work for which this 5rcrmit is issued. I shall not cmploy any lrcrson in any manncr <br />so as to bcconr subjcct to thc workers' compensalion laws of California. and agree lhat if I should becomc subicct to the <br />workers' compcnsation provisions of Sc.ction 3700 of the l-:bor Codc. I shall. forthwilh comply wilh thosc provisions.. <br />WARNING: Failure to sccurc workers'compcnsntion coverage is unlawful. and shall subjcct an cmploycr lo criminal pcnaltics snd <br />civil fines up to one hundred thousand dollars ($100.000). in addition to thc cost of compensation. darnages 8s providcd for the <br />Section 3076 of the l-abor Code. intcrcst and atlorncy's fc"es. <br />Applicant: <br />I lcpxsgD c0t{TR lcT(rR <br />DECLARATTON <br />I hereby affirrn undcr penalty of pcrjury that I am licensed under provision of Chapter 9 (commcncing with Section 7000) of Division 3 <br />of the Business and Pmfessions Codc. and my license is in full force and effect. <br />Licensc Nunrbcr: <br />I )alt' <br />CONSTRUCTION LENDING AGENCY <br />I hercby rllirnr undcr lEnally of lErjury that thsc is a constructhn hrding agcmy for thc psfomncc of lhc work for which this fsmit is <br />issucd (Sc. 3097. Civ. C.). <br />lxndcr's Namc: <br />APPLTCANT DECLARATION <br />I lrcrcby alllrrn ultder penalty ol' pcrjury onc of thc following dcclitral iotts: <br />Dcrrxrlitiotr Pcrntits-Ashcstos Notiljcation [:eclcral Rcgulations ('l'itlc 40. Part6) <br />-Rcquircd <br />l.cllcr of Notilication <br />-l <br />ccnity th{t lhe fedcralrcgulatkrns rcgardinS ashcstos rcmovdlarc not applicablc k) lhis projct <br />_l ccrlify lhul I hrvc rcad rhis applicnlion ad sldrc th{r lhc ntmvc inli)rntotiol is conccl. I ilgre to comply wilh all Cily snd Coutrly <br />odintnccs {nd Stdtc kws rclatirg lo huilding constructior. ard hcrchy aulhorizc rcprcsnlalivcs of this Cily nnd County lo cnlcr uF)n lhc <br />atnvc nrnthncd pmfrrly lbr inspcction purymscs. <br />Applicant or Agent <br />I'ermilee nttnre <br />I)ale: <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-trao/Drain Line <br />l\Iain Drain/Pool Pipinq <br />Fill Line/Back FIow <br />Pool Heaterlcas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewerl3ap <br />Back Flow Device <br />Rouqh Plumbinq <br />Final Gas Test <br />Meter Release tl It Z <br />FINAL tolu lfu D{a,M 7^(E <br />Notes, Remarks, Etc. <br />Expircs: <br />Carrier: