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PLUM BING-INSPECTOR HECORD <br />APPROVALS DATE ID/SIG COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby afftrm urdcr Fnshy of pcrjury thrr I m crcmpt from thc Contreto6' Lirnrc [rw for thc followin8 rcamn (Sa.?031..5 <br />Busincss atd hofcsion Codc)i Any City or County which rcquircs s pcmit lo @nstruct, 8ltc, impmrc, dcmlish or rcpqir my <br />structurc. prbr to its is$m€, rls rcquircs the applLEnt for sEh pcmit to file s sigred ststcrcnt thsl lE or slE is lienscd puEusot <br />lo Ihc provisions of th Contrrctor's Li.rn$d hw (Chrplcr 9. Comrcing with Sctbo 7000 of Division 3 of thc Busircss ud <br />PDfcssionsCodc)qthattcqsh€iscrctrrptttsrfrcmdrdthcbosisforthcalhgedexerption. AnyvblstbnofS€lhn703l.5byany <br />applicant for a pmit subirts the applicsnt to 8 civil pcnalty of not mrc the live hundred dollars (S5fi)). <br />-1. <br />as owncr of thc property. or my cmployecs with wagcs as thcir solc compensation. will do the work and thc structure is not <br />intend or offered for sale (Soc.7044, Busincss and Prrofessions Code: The Contractor's Licensc l-aw does not apply to an owner of <br />lhc propcrty who builds or inprows thcrcon, alrd who docs mrch work himself or hcrsclf or through his or hcr own cmployccs, <br />provided that such imSnorrcnrnts are not intended or offered for salc. If. however, the building or improvenrnt is soH within onc )rcar <br />of conpbtion, thc Owner Builder will have thc burden of proving that he or she dirt not build or inprorc the propcrty for the purposc of <br />salc). <br />_1. as owner of thc propcrty. anr exclusivcly conlracting with liccnscd controctors to construct thc projcct (Scc. 7(}{4. Busincss <br />and Rofbsskrn Codc: Thc Contraclor's l-iccnsc Law docs not apply lo an owncr of propcrty who builds or inrprovcs thcrcon. <br />and who conlracts tirr such projccts with a Conlraclor(s) liccnscd pursuant to thc Contractor's Licensc l-aw). <br />-IantcxclnptundcrScction-.B.&P'C.f.orthisrcason. <br />woRKERt' arnn*o*tnrron <br />DFCLARATION <br />I hcrcby affirm undcr penalty of prjury onc of thc following dcclarations: <br />-l <br />have and will maintain a Certificatc of Conscnt to Self-lnsurc for workcrs' compensation. as provided for by Scction 3700 of the <br />[:bor Code, for the pcrformancc of the work for which thc pcrmit is issued. <br />-l <br />havc and will maintain workers' compensation insurancc. as required by Scction 3700 of thc L-abor Code, for thc pcrfonnancc of <br />the work for which this pcrmit is issued. My workcrs' compensation insurarrce carrier ard policy numhr are: <br />a <br />Policy 6 t ltlr?- <br />I <br />-l <br />certify that in the;rcrfornrancc of thc work for which this Jrcrrnit is issued, I shall not employ any pcrson in anyrnbrrner <br />so as to become subict to the workcrs' conrpcnsalion laws of California. and agrce that if I should hecome subjcct lo the <br />workcrs' compensation provisions of Scction 3700 of the Latxrr Codc. I shall. forthwilh comply with thosc provisions.. <br />a <br />WARNING: Failurc lo secure workers' compcnsation covcragc is unlawful. and shalt subjcct an cmploycr to criminal fiiuhies and <br />addition to the cost of compcnsation. damagcs as providcd for thccivil lincs up to onc hundred lhousand dollars ($l ill <br />Scction 307e9 the Labor Codc, intcrcst and fccs. <br />LICENSED CONTRACTOR <br />DTCLARATION <br />I hcrcby alfirm undcr penalty of pcrjury that I arn liccnscd undcr pmvision of Chapter 9 (comrrcncing with Scction 7000) of Division 3 <br />of the Business and Profcssions Code, arxl nry liccnsc is in full forcc and *"r. <br />Liccnse Numbcr:1esb8 <br />I hcrcby aflrm undcr Fnalty ofpcrjury that thcrc is a construdion lcnding agcncy for thc pcrfornunce oflhc work for which lhis lErmit is <br />issucd (Scc. 3097. Civ. C.). <br />kndcr's Narnc: <br />l-cntlcr's Adclrcss: <br />APPLICANT DECI ARATION <br />I hcrcby allinn under penalty of pcrjury onc ol'thc folkrwing dcclarations: <br />Dcrnolition Pcrmits-Asbcstos Notification Fcdcral Rcgulalions (Titlc 40. Part6) <br />_Rcquircd lrttcr of Notification <br />-l <br />c{rrify that the fedcr8l rcguhtions Eguding asbestos rcmval re mt applicabb to this pDirt. <br />_l cc{rify lhat I have rcad thii applicstion Ud st8lc thrr the sbovc infomtion is cml. I rgrE to olply with lll City 8rd Counly <br />ordimrccs ard Stalc [rws rhting to building conslruclioc ard hcrcby ruthorire rcpresntltiuf this Cily aod Counly lo eils upon the <br />abovc mcntioned propcrty for <br />Applicant or Agenl <br />Permitee name <br />*,", ahzfzl <br />UNDER GROUND <br />Waste & Vent <br />Water-Under floor <br />Gas-Underf Ioor <br />Buildinq Sewer <br />ArealStorm Drain <br />I nterceptor/ CIarif ier <br />TOP OUT I h <br />Waste & Vent V tfElu bA.IFI ( <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 />N/ain Drain/Pool Pipinq <br />Fill Line/Back Flow <br />Pool Heaterlcas 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 tr I <br />FINAL DWVS'I <br />Notes, Remarks, Etc. <br />t <br />Dale:( )rvlrcr: <br />c""i",, ?Tf,rg f ortuD <br />'F',Idrz <br />dF (l+ <br />- <br />tut'Al-A