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PLUMBING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUTLDER DELCARATION <br />I hcrcby aflirm undcr penalty of pcrjury that I am cxcmpt frcm the ConlrrctoE' Liensc kw for thc following rcaon (Scc.7031.5 <br />Busincss and Profcssion Codc): Any City or County whhh rcquircs r lErmil to construct. altcr, imprcvc. dcmlish or rcpair uy <br />strucfirc. Fior to ils issuancc. elso rcquircs thc tpplicant for such lrcrmit to filc a signcd ststcmnl thrt hc or shc is licensd pursrnt <br />ro rhc Fovisions of thc Contractor's Liccn$d tlw (Chaptcr 9, Comrcing vith Setion 7000 of Division 3 of thc Busircss and <br />PmfcssionsCodc)orthathcorshciscxcmpllhscfrcmaixlthcbasisforthcallcgcdcxctr{,tion. AnyviolstionofsctitnT03l,5byany <br />applicanl for a lrcrmiI subjcts the applicsnt to a civil pcnally ofnol mrc thil five hundrcd dollars ($50O). <br />-1. <br />as owncr of thc prclrcrty, or my cmplo)rcs with wagcs as thcir slc comlEnsalion, will do tlrc work and thc stnrc1rc is ret <br />inrcndc{ or offcrcd for slc (SN,7(X4. Busincss and Prcfcssions Codc: The Contnctor's Liccn* [:w docs not apply to il osrer of <br />thc pmlEny wlx, builds or impmrcs lhcmn, ard wlb dms rch mrt himsclf o. hcrclf or lhmugh his or hcr own cmployccs. <br />pmvidcd that such imprcrcmnts rc rct inlended or offcrcd for slc. lf, lDscrci the buiHing or itr{rrcwmnl is sld wilhin onc }eu <br />of @rphtion. thc Owncr Buildcr will h8w thc bordcn of Fovirg that hc or shc did mt buiH or imgmrc 0rc lmpcty for thc purtDs of <br />slc). <br />_1. as owncr of thc Jrcpcrty. am cxclusivcly cotrtrscting with liccnrcd conlnclos to construct thc projEt (Ss. 7(X4, Busirc$ <br />and ProfcssionCodc:TheContractor'sLiccnrcLawdocsmtapplytoanownerofprolrcnywhobuildsorimprcvesthercon, <br />and who qrntrcts for such pmjccts with a Conlmcto(s) liccnrcd pursumt to the Contraclor's Liccns [5u), <br />-l <br />sm cxempt undcr Sction-. B. & P.C. for lhis rcaen. <br />l)atc: <br />WoRKFRS' COMPEI{S ^ flON <br />DECI ARATION <br />I hereby affirrnundcr penaltyof grerjuryonc of the following dc.clarations: <br />_I have and will maintain a Certificate of Consent to Self-lnsure for workers' compensation, as provided for by Section 3700 of the <br />Labor Codc, for thc performance of the work for which the permit is issucd. <br />-l <br />havc and will maintain workers' comp€nsation insurarrce, as rcquircd by Section 3700 of the l-abor Codc, for the performance of <br />the work for which this permit is issr.red. My workers' compensalion insurance carrier ard plicy numhr are: <br />Policy Numbcr: Expircs: <br />_l certify that in the pcrformancc of thc work for which this pcrmit is issucd. I shall not cmploy any pcrson in any manncr <br />so as to becornc subict to thc workers' compensalion laws of California, and agrce that if I should become subpct to thc <br />workcrs' compcnsation provisions of Scction 3700 of the l-abor Codc. I shall. forthwith comply with those provisions.. <br />WARNING: Failurc to sccurc workers' compensation covcragc is unlawful. and shall subjcct an employcr to criminal pcnaltics and <br />civil fincs up to one hundred thousand dollars ($100,000), in addition to thc cost of compcnsation, damagcs ss providcd for thc <br />Scction 3076 of thc Labor Codc, intcrcst and attorncy's fccs. <br />flo la. <br />LICENSED CONTITACTOR <br />NECLARATION <br />I hcrcby alfirm urrdcr pcnalty of pc{ury that I am liccnscd undcr provision of Chaptcr 9 (cornnrcncing with Scction 7000) of Division 3 <br />of thc Busincss and Profcssions Codc, and my liccnsc is in full forcc und cffcct. <br />Licensc <br />Date: <br />W <br />I hcrcby aflrm undcr lEnaky of Frjury that thcrc is a @nstructk n lcnding lgcrcy for thc Jrcrfomrcc of thc work for which this pcmit is <br />issued (Se. 3097. Civ. C.). <br />lrndcr's Nsmc: <br />lrndcr's Addrcss: <br />APPT ICANT DECLARATION <br />I hcrcby allirnr undcr pnalty of pcrjury onc of thc l'olkrwing dcclarations: <br />Dcnrolition Pcrmits-Asbcstos Notification Fcdcral Rcgulations (Titlc 40. Parl6) <br />-Rcquircd <br />[*ttcr of Notification <br />-l <br />ccrrify that thc fcdcral rcgulations rcgarding ashcslos rcmval rc not applicsblc to this pmjst, <br />_l ccrtify that I have rcad this applicalion ard statc thst rhc abovc informtion is const. I agre lo @mply with rll Cityand County <br />ordinanccs .nd Sltrtc kws rclatirg to building construclion. ud hcrcby suthorirc rcprcscntativcs ofthis City anrl County to cnlcr uJDn lhc <br />obovc mntioncd prepcny for insFction purlDss. <br />Applicant or Agent <br />Permitee namc l nrirrl )' <br />Date: <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 />ltlain Drain/Pool Pipinq <br />Fill Line/Back Flow <br />Pool Heat erlcas Line <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewerlcap <br />Back FIow Device <br />Rough Plumbing <br />Final Gas Test <br />Meter Release I tl -72 <br />F!NAL t|fi3/2t t@m v-w <br />Notes, Remarks, Etc. <br />Owner:_ <br />_License Number: <br />Contractor: