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PLUM BING-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby rmrm urd€r Fmlty of Jrcrjury thst I m excr{,t fmm the Contnctffi' Lien$ lrw for thc following rer$tr (Soc.7031.5 <br />Busincss srd hofc$ion Code): Any City or County whbh Bquircs 8 lrcmit to onilnrct. alls. impmrc, dcmlish or rcprir any <br />structurc. prior 10 its issuance. also rcquircs the applicant for such pcmit to filc a signcd slstcmnl that hc or she is liccnsd pumsnt <br />lo thc prcvisiom of thc Conlnclor's Licused law (Ch8pler 9. Comming wilh Sstion 7000 of Divbion 3 of the Busircss ang <br />PpfessionsCodc)orthathcorsheiscxcmptlhercfromandthebssisforthcallegederemption. AnyviohlionofsetionT03l.5byrny' <br />applicsnt for a pcmit subirts thc applicsnt to I civil lrcnslty of rct mrc tho fivc hundrcd dollus (S50O). <br />-1, <br />as owner of lhe property. or my cmplolaes wilh wagcs as lheir sole comlrcnsalion. willdo thc work nnd the structurc is not <br />inte:rdcd or offcred for sale (Scc.7044. Business and Professions Code: Thc Contractor's License Law docs not apply to an owncr of <br />the propcrty who builds or improves thereon. and who does such work himsclf or hcrsclf or through his or hcr own employees. <br />providcd that such improvenrcnts ere nol intended or offcrcd for sah. If. howevcr. the building or improvenpnl is sold within onc )tar <br />of completkrn. the Owner Buildcr will have the burden of proving that he or she did not build or improve the propcrry for the purynsc of <br />sah). <br />_1. as owncr of thc proprty. anr cxclusivcly contracting with liccnscd conlrccl()rs lo conslruct thc projccl (Scc. 7W. Busincss <br />and Pnrfssion Clode: The Contraclor's l.iccnse Law docs not apply to an owncr of proJrcrty who builds or improvcs thcreon. <br />and who conlracls for such prrrjccts with a Contruclor(s) liccnscd pursuanl lo lhc Contractor's Liccnsc Law). <br />_l arrr cxcnrpt urrdcr Scction_. B. & P.C. for this rcasorr. <br />l)ale:()u'ner: <br />IYORK EIIS' CONIPENSA'I'ION <br />III'CLARATION <br />I hcreby aflirm undcr pcnalty of Jrcrjury one of the following dc"clarations: <br />_l have and will maintain a Certificatc of Consent to Self-lnsurc for workers' compcnsalion. as provided for by Section 37fi) of thc <br />Labor Codc, for the performance of thc work for which thc pcrmit is issucd. <br />_l havc and will nraintain workcrs'insurancc. as rcquircd by.Scction 37fi) of the labor Code. for the pcrforrnancc of <br />thc work tbr which c<lmJrcnsation insurancc carricr and Jnlicy number arc: <br />- <br />Policy a <br />_l ccrrify thal in thc perfornuncc of thc work for which this pcrmit is issucd. I shall not cmploy any pcrson in any manner <br />so as to bccomc subjcct to thc workcrs'conrpensation laws of California. and ugrce that if I should becomc subjcrt to thc <br />workcrs' conrJrcnsation provisions of Scction 3700 of thc Latnr Codc. I shall. forthwith u'ith <br />WARNING: Failurc to sccurc workcrs' comJrcnsalion covcragc <br />civil lincs up lo onc hundrcd thousand dollars ($100.m0). in <br />ls criminal pcnaltics and <br />as provided for thc <br />Section .1076 of thc l-abor Codc. intcrcst and attorney's fccs. <br />,rr",'7'cZJ-"2!0 <br />I hcrcby atlirrn undcr pnalty of perjury that I am liccnscd under provision of Chapler 9 (comrnencing with Section 7m0) of Divisidr 3 <br />of thc and cffcct. <br />Liccnsc <br />Dil", '7;ZJ--bfu <br />CONSTR.UCTION LENDING AG ENCY <br />I hereby affirm undcr penalty of pcrjury that lhere is a construction lending agcncy for tirc performance of the work for which this <br />issued (Scc. 3097, Civ. C.). <br />ls <br />Lcndcr's Narnc: <br />l.cnder's Addrcss: <br />APPLICANT DECLARAI'ION <br />I hcrcby allirrn urrtlcr pcnalty of pcrjury olrc of thc folkrwing tlccltratiorrs: <br />Dcnrolitiorr ['crnrits-Asbeslos Nolifictliorr Frcdcral Rcgulations ('l'itlc 40. Prrl(r) <br />-Rcqu <br />irctl l-cltcr of Notifical krrt <br />to lhis projccl. <br />I agrcr to conrply with all City and County <br />of this City and County to enter ufnn thc <br />abovc rncnlioncd propcrty for ins;rcction <br />Applicant or Agent <br />Itermilee n&me <br />asbcsl<ls renmval arc not <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf loor <br />Building Sewer <br />ArealStorm Drain <br />I nterceptor/ Clarif ier <br />TOP OUT n <br />Waste & Vent 12n-Zl vtLl4t\ <br />Water Piping V-q'-?l 'UJllhr,) <br />Gas Pipinq U il-/ <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOL/SPA <br />P-trap/Drain Line <br />N/ain Drain/Pool Pipinq <br />Fill Line/Back FIow <br />Pool Heater/Gas Line <br />Misce!!aneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary SewerlCao <br />Back Flow Device <br />Rouqh Plumbinq <br />Fina! Gas Test <br />Meter Release //.a_ <br />FINAL <br />Remarks Etc. <br />.tl <br />iln <br />r,_Licensc <br />rcgardirrg