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PLUMBI NG.INSPECTOR RECORD a <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER I'EI,CARATION <br />I h6cby a,fm udq padty of pCjury thd I m q@F &om rhc CrtdractoE' Licm ls for thc followiog @tr (sc.7031.5 <br />Buins aod Profcssion Codc): Any City or Couty wtich EquiE 8 Fmn to @flrruct, ahs, improvc doolish or npeh my <br />structw, prior ro its iswc, also rcquirc thc appliat for such pcrmit to file a signcd starmot thd hr or slE b licosod F$mstt <br />to thc pmvisioB of thc Contrrctor'B Licmscd Law (Chrptq 9, Comming with Sction 7000 of Division 3 of thc Buine ud <br />ProfcsiomCo&)orthathcorslrciJqarptfiqc&omDdrhcbosbforthcallcgcdqmpriou AnyviolatboofsccrboT03l.5byay <br />applicut for 8 p6nit subjcrs thc applicut to a civil pcnalty of rot rcrc the fivc hundrcd dollan (5500). <br />_1. s oma of thc prcpqty, or my cmployc wirh wage r rhcir $lc omps[diorl. will do thc wqk ad ttE ltructw b rct <br />intodcd or ofrqcd for slc (Sc.7M4, &sins od Pmft*sioB Codc Thc Crdra.lor's Li@ lrw doc lot 4ply to m offi6 of <br />$c proFty who builds or improu tlson, ud who &c sh wrt himclf or hqslf or thrcugh hir or ho om oploycca, <br />providcd that such imlmvqndts rc mt intadEd or off$d for slc. t[, howrc, thc huilditrg or imprcvqqft is old within orc ]6 <br />of orrpleba thc Ovma Buil,:lq wil haw thc htrd6 of proving tlra hc or rhc dll mt tuild u im!rcw 0E Fopaty fur thr Frpos of <br />sh). <br />-1, <br />r omq of thc p(opsty, m qcluivcly contreting with licqEcd contractoB to oNtruct thc Fojd (Se. 7(x4. B{sinB <br />sd Proftsbn Co&: Thc Conraclor's Lic6$ lrw doB not spply to e oma of propcty who builds or imprcvB tha6G <br />ud who @ntsrcB hr such pojcrs with a Contracro(3) licsEcd prrBua[ ro th€ Cootrctor'! Li(re kw), <br />-l <br />am exempt undcr B. & P.C. for this reason. <br />WORKERS' COMPENSATION <br />DECLI\IIATION <br />I hereby affrm under penalty of perjury one of the following declarations: <br />_l have and will maintain a Certificate of Conscnt to Self-lnsure for workers' comp€nsdion, ar providcd for by Secrion 3700 of the <br />Labor Code, for the perfonnance of the work for which the pernrit is issued. <br />_l have and will maintain workcrs' compcnsation insurance, as roquired by Section 3700 of thc l-abor Code, for the pcrformance of <br />the work for which this pennit is issued" My workcrs' compensation insurancc carric and policy numh are: <br />.r,ri-. QtLr.C g^r, n \v g u r.rt^rc- 4o <br />Policy c 90t A ' l'?oLL t <br />_l cer:ti& that in the pcrformance of thc work for which this pcrmit is issucd, I shall not ernploy any pcrson in any manner <br />so as to become subject to the workers' compcasation laws of California, and agrec that if I should bocome subject to thc <br />workers' compensation provisions of Sedion 3700 of the l-abor Codq I shall. forthwith comply with those provisions.. <br />a <br />WARNING: Failure to secure workers' <br />civil fines up to one hundred thousand <br />comperuation coverage <br />dollars ($100,000), in <br />is unlawful. and subject an employer to crimind pauhies and <br />addition the of compensatioru damages as provided for the <br />Section 3076 of the tabor Code, intqest and attorney's <br />oeetL' J O' .2oJ-,1 <br />I hereby affrrm undcr penalty of perjury that I am licensod 9 (commarcing with Section 7000) of Division 3 <br />of the Business and Professions Code, and my liccnse is in full force and effect. <br />License Class: Liccnse <br />D$e: L' ,10' ,2d Ll <br />I hereby affrm under penalty of perjury that thcre <br />issued (Sec. 3097, Civ. C.). <br />agency for the pcrformance of the work for which this perrnil is <br />knder's Name: <br />I-endcr's Address: <br />APPLICANT DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: <br />Dernolition Permits-Asbestos Notif-rcation Fcderal Regulations (Title 40, Part6) <br />_Required Lrttcr of Notification <br />_l certi& that the federal rcgulations regarding asbestos rernoval are not applicable to this projcct. <br />_l certi& that I have read this application and state that the abovc with all City and County <br />and County to entcr upon theordinances and State laws rclating to building <br />above mentioned property for <br />Permitce name <br />and <br />o*e, L. 70 ' 2a >.) <br />UNDER GROUND -4 ;) <br />Waste & Vent tlNuTIl -nfoetD -- <br />Water-Under floor ttt U\ <br />Gas-Underfloor <br />Building Sewer <br />Area/Storm Drain <br />I nterceptor/ Cla rifier <br />TOP OUT <br />Waste & Vent I I, I ,a <br />Water Piping dl'iltlht aurh{gl 7V <br />Gas Pipinq 1-I <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 />Fill 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 />I I lt I ^{) <br />Rough Plumbing ill3ltAt b <br />Final Gas Test tl <br />Meter Release n It I .a <br />FINAL bltr ltt AWilh ruK <br />Notes, Remarks, Etc.tl <br />Applicant or Agent Signature:. <br />is correct. 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