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PLU M BI NG.! NSPECTOR RECORD ra APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DEI,CARATTON I h6cby afiim und6 poalty of pqjury that I m qcmpt &om thc Coilracto6' Lic@ Lrw for thc followiag rcn (Se.7031.5 Buios ad Prcfsion Codc): Ary City or Coulty which rcquira a po'mit to @ostruct. alt6. improvg damlbh or npair oy strcturq prbr to its issurec slso rcquic thc applicut for such pcmit to filc 8 8igncd stdmr thal hc or dE is licascd pwsnt to thc provisioB of the Contretor's Liccmcd lrw (Chspt6 9, Comacing with Sction 7000 of Division 3 of thc Bsin6 4d Profxioro Codc) or that hc or shc is cxmpt thqâ‚¬&om md thc b0sis for thc allegcd aopion. Any vioLrtion of Sctbn 7031.5 by ey applicmtforapqmitsubjctsthc applimttoacivilpcruftyofnotmorcthefivchuodroddollss($500). -1, as owner of the property, or my ernployecs with wages as their solc compersdion, wil do ttte work ard the snraure b not intcndcd orofu for sale (Se.7044, Business and hofesions Code: The Contractor's Liccnsc [aw docs not apply to anownâ‚¬r of the propcrt'y who hrilds or improve thcron, and who does such work himsclf or hcmclf or through his or hcr own qnployce. provided that such improvanrents tre not intenH oroftrcd for salc. I[, howwer, thc hliHing or improvemcnt is soH within one ]â‚¬ar of complaioq the Ovner Builda will have thc hrden of proving tha he or shc did not hrild or improve the property for thc purposc of sale). -1, as owner ofthe propâ‚¬rty, am cxclusively contracting with licenscd contractors to construct ttrc project (Soc. 7044, Brsiness and hoftssbo Code: The Contractor's Liccnse Law does not apply to an owncr of propcrty who builds or improves thcreon, and who contracts for such projeds with a Contracto(s) liccnsod pursuant to thc Cpntractor'g Licqtsc l-aw). -l am excmpt unda Section-, B. & P.C. forthis reason. f)qlo. WORKERTI' COMPEN SATION DECLARATION I hcreby affrm under penalty of perjury one of the following declarations: -l have and will maintain a Certificatc of Consent to Sclf-lnsure for workers' compcnsation, as providcd fot by Section 3700 of the I-abor Code for the performancc of thc work for which the pcrrnit b issued. -l have and will maintain workers' compensation insurance, as required by Section 3700 of thc labor Code, for the pcrformance of the work for which this permit is issued. My workers' comperuation insurance carier and policy number are: Policy Numbcr: Expires: _l ccrti$ that in the performance of thc work for which this pcrmit is issucd. I shall not cmploy any person in any manner so ils to become subject to the workcrs' compensation laws of California. and agree that if I should become subject to thc workers' compensation provisions of Scction 3700 of the Labor Code. I shall, forthwilh comply with thosc provisions.. WARNING: Failre to suc wkm' ompquation covwge is ulawful. ud shall subjet I @ploy6 to cimind psulics md cMl fuc up to ooc hutrdrcd thoMd dollm ($100.000). in sddition to thc cog of compcostion, darage a prcvidcd for thc Sction 3076 of thc lrbor Codq intaet ud aonry's fe. A ^^l:--.. LICENSED CONTRACTOR DECT.,ARATION I hereby affinn under penalty of perjury that I arn licensod under provision of Chapto 9 (commancing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. Number:- W I hmby affm undo penalty of psjury that th@ is a construction lcodiry agmcy for thc pqfolruc of thc mrk fur which this pqrnit b Civ. C.). l,cnder's Ad&ess: APPLICANT DECIIIRATION I hcr,*y affimt under penalty of pcrjury one of the following declarations: Demolition Permits-Asbestos Notification Federal Regulations (Title 40, Part6) -Rcquired lrtter of Notificaion -l csrirythd thcftdalquhtioro rqrdiag rbatomvalre norrppliebhto thi! prcj.d. -l 6ti& thd I hsvc rad thb applicatioa od ststc that thc alovc idorDdb! is @nEt. I rgr to ooply with all Cily ud County ordire6 md Stdc LM rcldirg to buiuing oDdructio!, md hs6y ruthori4 Epr6atdiE of thi! Cily snd Couty to 616 rpotr thc aborc mationcd prcpary for inspccion purpos Applicant or Agcnt I'trillilcc ililrnc (priilt): UNDER GROUND Waste & Vent Water-Under floor Gas-Underfloor Building Sewer Area/Storm Drain I nterceptor/ Cla rifier TOP OUT Waste & Vent Water Piping Gas Piping Roof Drain Tub/Shower Test Rough Water Heater POOL/SPA P-trap/Drain Line ,/,a .J Main Drain/Pool Piping 5/n 70/rf{unrau r@ Fill Line/Back Flow /f \.a Pool Heater/Gas Line -k4 Cr?/a>,t Miscellaneous '*f0oe flod Gas Service ./tr" lylw V Water Service Lawn Sprinkler Sanitary SewerlCao Back Flow Device Roush Plumbinq Final Gas Test Meter Release I Itl ,, FINAL 'r/ ,{vl Wrfu wu Notes, Remarks, Etc. License Class:- Drte: '-^f