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MECHANICAL-INSPECTOR RECORD <br />APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hoeby affirm undo peralty of prjury that I m exempt from the Contractors' License Law for the following re6on (Ss.703 1,5 <br />Buinss md Profmion Code): Any City or County which require a pmit to construct. alto, improve, dmolish or repair my <br />structue. prior to its isumce. also requirB the applicml for such pemit to file a signed statment that he or she is licmed pusudt <br />to the provisios of the Contractor's Licensed law (Chapter 9, Commencing with Strtion 7000 of Division 3 of the Bwiness md <br />Prof€ssions Code) or that he or she is exeinpt thqefrom md the basis for the alleged exmpliu. Any violation of Section 7031.5 by @y <br />applicantforapmitsubjststhe appticanttoacivilpenaltyofnotrnorethilfivehundrltdouarp.{€600). <br />_1. u omr of the properiy. or my mployffi with wag6 6 lheir sole compensation, rvill do the work md the structue is not <br />intmded oroffsedforsale(S@.TM4,BuinesandProfessionsCoderTheContractor'sLicemelzwdoesnotapplytooownqof <br />the prcperty who builds or improve thqon md who doe such rvork himself or hmelf or through his or her om mployes, <br />provided that such improvments ile not intmded or offsed for sle. lf, howfls, the buildif,g or improvmmt is sold within one )@ <br />ofcompletioe the Ownq Buildq will have the burdo ofproving that he or she did not build or imprcve the propety for the purpos of <br />ule). <br />_1, 6 offiq of the propsty. m exclusively contracling with licamed contractorsto construct the prcjtrt (56. 7044. Buins <br />md Pmfesion Code: The Contractor's License Law do* not apply to m owns ofproperty who builds or improvB ths@n, <br />and who contmcls for such prcjects with a Contracto(s) licemed purs@nt to the Contraclor's LiceNe Law). <br />-l <br />m exempt undq Sation-, B. & P.C. for this rruon. <br />Drle:_ Owner: <br />WORKERS' CO]\IPENSAI'ION <br />DECLARATION <br />I hereby affirm under penalty oIpojury one ofthe following declaralions: <br />I hare ard rvill rnaintair a Certilicate ofConsent to Self-lnsure for workers' conrpensalion, m provided for by Section 3700 ofthe <br />Labor Code, for lhe pqfonuance ofthe rvork ftrr rvhich lhe psmit is issued. <br />_l have and will maintain workers' compensation insurance. d required by Section 3700 ofthe Labor Cod€. for the pqfomance of <br />the work for which this pennit is issued. My workets' compeNation insurmce cmier md policy number oe: <br />Policr Nurnber: E*pires, <br />- <br />_l certiry that in the poformance of the work for which this porrit is issued, I shall not employ any pmon in any rnano <br />w ctobeomesubjecttothcwork6s'composationlawsofCalifomia.udagreethatiflshouldbecomesubjecttothe <br />work6' compffiatioo ptovisioo of Seclion 3700 of the Labor Code. t shall, forthwith comply rvith thos provisiom.. <br />WARNING: Failure to secue workqs' compemation coverage is unlawful. md shall an mployo to qiminal penaltis and <br />civil lmes up to one hundred thoused dolltrs ln the dronages o provided for the <br />Section 3076 Code. inttrest ild <br />q. <br />I hereby affirm under penalty ofpsjury that I iln licosd undfl provision 9 (commencing wilh Sfition 7000) of Division -l <br />of the Busines ud Professiom Code. md my license is in full force md effect. <br />+,,1License <br />I hwby affrm undu penalty of ptrjury that <br />issued (Src. 3097. Civ. C.). <br />Lentler's Name <br />- <br />$a lending agency for the pefommce of the work for which this permit is <br />Lender's Addras: <br />- <br />ATTIrcAXI.UECIABAIIQN <br />I hoeby aflinn under penalty of perjury one ofthe following drclaations: <br />Denrolition Permits-Asbestos Notification Federal Regulalio0s (Tille 40. Pd6) <br />-Recluired <br />Letter of Notification <br />-l <br />certirythat the federalregulations regrdirg cbetos rernovalae not applicable to this prcjtrt. <br />that read this with all City and County <br />md Coutyto entq upon theLaws relating to <br />above propeny for <br />Applicant <br />Pmnitee <br />Agmt <br />state that the <br />Appliances <br />Metal Fire Place <br />Evaporative Cooler <br />Furnace <br />Compressor <br />Misc. Equipment <br />Duct Work <br />Pre-lnsulation <br />lnsulation <br />Smoke Detectors lnstalled <br />Rough Ductwork <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Range <br />Other <br />Hood <br />Tvpe I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openings <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech <br />Final Test <br />Meter Release <br />FINAL V/?trlno 7b^^at/-zA ) <br />Notes, Remarks, Etc a t I (I <br />"^",uf 6lq