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PLUM B! NG.I NSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI'ARATION <br />I h6cby rffm und6 pcn8hy of pqjury thd I m qcmpt from thc Contractos' Licw L:w for thc fullowiq mn (Se.7031.5 <br />Buines and Prcfeion Codc): Atry City or Courily which rcquic a ponit to oostrucl, altq, imgrcvc doolish or cpair ay <br />structurcpriortoirs issuacc.alsorcquisthceplimtforsuchpcmittofilcasigncdstalmt thrrhcorCEblicoscd plmal <br />to fic prcvisioN of thc Coohrctor's Licoscd Lrw (Chspt6 9, Commhg with Sction 7000 of Division 3 of thc BuitB md <br />Prcf*iom Codc) or that hc tr slrc is qmpt thc&om 8nd tlrc bsis for thc dlcgcd aopion. Atry violatioo of Sction 7031.5 by ey <br />applicut for a pannit subjets thc appti@t to 8 civil pculty of not morc tlur fivc hurdrcd dollm ($500). <br />-[. <br />as owner of thc propcrty, or my emplo]ces with wages as their sole compcnsation, will do tttc work and thc stnrcturc is not <br />intendcd or offcrd for sale (Se.7044, Business and Profesions Code: Thc Contractor's Liccnsc l-aw does not apply to an owner of <br />the propcrty who btrilds or improve thcron, and who does such work himself or hersclf or through his or her own employeca, <br />providcd that such improvcrnents are not intcnded oroffercd for sale. I[ howwer, the building or improvement is rcld within one ],Ear <br />of completion, the Orvner Buildcr will have the hrden of pnoving tha he or shc did not build or improvc ttrc propcrty for the purposc of <br />sale). <br />-1, <br />as owncr of the propcrty, arn cxclusively contracting with licarsed contracton to construct thc projocr (Soc. 7044, Brsiness <br />and hof€ssion Code: Thc Contraclor's License Law docs not apply to an owncr of property who builds or improve thcreon" <br />and who contracr for such trojec'ts with a Contracto(s) licerccd punruant to the Contractor's Licensc law). <br />-I <br />am cxempt under Section-, B. & P.C. for this reason. <br />Owner: <br />WORIGRS' COM'ENSAT'ON <br />DT'.cllUIATION <br />I hacby allim undo pcnaltyof po'juryonc ofthc following delmtioro: <br />-l <br />havc ild will msintah I Cqtificatc of ColMt to Sclf-lNurc for wrko' ompcruation, I providcd for by Setion 3700 of thc <br />bbor Codc, for thc psfomcc of thc rcrk for vtich thc ponit is issucd, <br />{ffh"u" "nd <br />*ilt ,aintain workm' compcruation ircurecc, I rcquircd by Sction 3700 of thc Libor Codc, for thc pqfomecc of <br />tlic work for which this pemit is isucd. My workc' compcnsaion imurucc cui6 ed lDlicy numbs sc:u. <br />Policy ,. <br />fr"*i$ that in the performance of the work for which this permit is issued. I shall not ernploy any pemon in any manner <br />so as to become subject to the worters' comp€osation laws of California, and agree that if I strould become subject to the <br />workcrs' compauation provisions of Section 3700 of the l-abor Codq I shall, forthwith comply with thosc provisions.. <br />I- <br />I <br />WARNING: Failurc to sccure workers'compensation covcragc is unlawful, and shall subject an cmploycr to criminal penaltic and <br />civil fines up to onc hundrcd thousand dollars ($100,000), in addition to the cost of compcnsation, damagcs as provided for the <br />Section 3076 of the Labor Code, interest and attorn€y's fc6. <br />Dx", tlPlTFlA App*cenr: &*r* kurr*n <br />-t <br />1 I LICENSED CONTRACTOR <br />DTfIARATION <br />I hereby affirm under pcnalty of perjury that I am liccnsod undcr provision of Chapto 9 (commcncing with Sectbn 7000) of Division 3 <br />of thc Busincss and Profssioru Codc, and my liccnse is in fuU force and effcct. <br />License cbt Numbcr: <br />Dare: 6ln lUlA ll <br />rl <br />W <br />I hwby affm undo p68lty of pgjury that thcc is a @Btruclion lcnditrg rSacy for th€ pqfomce of thc work for which thb pqmit is <br />isucd (Se. 3097, Civ. C.). <br />Lender's Narne: <br />l,cndcr's Ad&ess: <br />APPLICANT DECTI\RATION <br />I hct*Draffirnr undcr pcnalty of ffiury one of the following doclarations: <br />Dernolition Pcrmits-Asbestos Notification Foderal Regulations (Title 40, Part6) <br />-Requirod <br />lcttcr of Notification <br />-l <br />certi& that the fedcral regulations regarding asbestos removal are not applicable to this projed. <br />and state that the above infonnation is correct. I agree to comply with all City and County <br />and hereby authorize rcpresantatives of this City and County to enter upon the <br />above mentioned property for inspection <br />Applicant or Agent <br />Permitee name <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underfloor <br />Buildinq Sewer <br />Area/Storm Drain <br />I nterceptor/ CIa rifier <br />TOP OUT <br />Waste & Vent <br />Water Pipinq <br />Gas Piping <br />Roof Drain <br />Tub/Shower Test <br />Rough Water Heater <br />POOL/SPA n <br />P-trap/Drain Line 1-t,l-v.\,a-€ <br />Main Drain/Pool Pipinq 'l- 14- lt ,/) trt\Y <br />Fill Line/Back Flow <br />Pool Heater/Gas Line <br />tr*)tu-lrr.tlN0 ?-t{-Ll D^J442 <br />Miscellaneous <br />Gas Service <br />Water Service <br />Lawn Sprinkler <br />Sanitary Sewerl0ap <br />Back Flow Device <br />L1 Baq -zt t F -ri" 4t <br />Rough Plumbing 1-l4.lt b?o {r. <br />Final Gas Test <br />Meter Release <br />FINAL Q-19.?t E2-t {r- <br />Notes, Remarks, Etc. <br />Dete:_ <br />Exoires:4l ie)2? <br />o,,", flfv.lzrru