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OWNER BUILDER Df, LCARATION <br />I heeby affm undo poalty of pcrjury that I m cxmpt fiom thc Contracto6' Lic@ Law for the following l@n (Sd.7031.5 <br />Buias and Profsion Codc): Any City or County which rcquirG a psmit to construcl. alta. improve dcmolish or rcpeir my <br />structuq prior ro hs issumcc. also require thc applicdt for such pmit to ftle a signcd statm@t thal hc or shc is licoscd punuut <br />to thc fovisioru of thc Contractor's Licoscd trw (Ch8pt6 9. Comencing wilh Sfttion 7000 of Division 3 of thc Bwincs and <br />ProfessiomCodc)orthathcorshciscxcmptthscfrommdthebasisfortheallegcdexmption. AnyviolationofScrrionT03l.5byany <br />applicant for a pmit subjfrts thc applicmt to a civil pcnalty of not more thu fivc hundred dollus ($500). <br />_1, re oms of the prcpcny, or my employe with waga a their sle compffialion, will do thc work ud thc structuc is not <br />intodcd or olTqcd for $lc (5€.7044. Businos md hofasioro Codc: Thc Contractor's Licm. L€w do6 not apply to d omq of <br />the propsly who builds or impove th@n. md who do6 such work himself or hmelf or thrcugh tis or ha own cmployco, <br />provided that such itnprovmts rc mt intodcd or ofTqcd for sle. lf. howwo. the tuilding or imlrcvoot is sld whhin onc )q <br />ofcomplction. the Owna Builds will havc thc budco ofproviru thd he or she did oot huild or improvc thc pmpo'ty for thc purpos of <br />sle). <br />_1, o ounq of thc propsty. m exclusivcly contracting with licffi€d contactoG to coEtruct lhc poj6l (Sc. 7044. Bsins <br />md Prokbn Codc: Thc Contmclor's Licssc Law doe not apply to u own6 of propcrty who builds or improvB thtron. <br />and who conttacls for such projcls with a Contmcto(s) licsed pE@t to the Contrsctor's LiccM lrw). <br />_l have md will mainlain a Certilicate of Consent to Sclf-lnsure for Norkqs' compmsation. a provided for by Sslion -1700 of the <br />Labor Code. for the peftrnnoce of thc rvork for rvhich the pmit is isued. <br />I have and will naintoin rvorken' compensalion insurance. as required by Srction 3700 ofthe t,abor Code. for the prforuance of <br />the work for rvhich this pemit is issued. My workos' conrpcnsation insurance canier md policy numbe ae: <br />Policy <br />_l certiry that in thc poformce of the work for which this psmit is issucd. I shall not mploy eny person in any mmno <br />rc m to become subjct lo thc work6' compcnstion laws of Califomia. od agE that if I should b.comc subjsl to lhe <br />workm' compc$ation prcvisioB of Sc<lion 3700 of thc Lsbor Code I shall. fonhwith comply with tho$ prcvisioN.. <br />WARNING: Failurc to suc mrk6' compcrualion cov@ge is unlawful. md shall subjd u mploys to qiminal pernltis md <br />civil fina up to onc hundred thoMd dollm ($100.000), in addition to the cost of compcmtion, damaga u provided for thc <br />Setion 3076 of thc Labor Codc int6€t md attomcy's fe. <br />I hwby affm undo pcnalty of pcrjury that I m licoscd undq 9 (comocing rvith Setion 7000) of Division 3 <br />of thc Buins md Prcfcssioro Code, md my licw is in fult forco 8nd effet. <br />r,*r.,, ?L,OCO15?O?llot e-nr,*, ll/ r/ r-l <br />Liceree <br />Applicdr or Agflt <br />Pfinite nane <br />_Licmc Number: 717--, aL <br />( onlraclor: <br />aeL <br />..n.r*I,*zur*o"^." <br />I hereby aflirrn undo poally ofperjury that thtre is a construction lending agmcy for the pqfonnmce ofthc rvork lor rvhich this pcnnit is <br />issued (Sec. 3097. Civ. C.). <br />Lendcr's Nanre: <br />landq's Ad&m: <br />APPLTCANT DECLARATION <br />I hetby aIEm u ndq penalty o f psj ury one o f the fo I lowing de laat ions: <br />Demolition Pmirs-Asb6tos Notificalion Fedgal ReSulalions (Title 40. Pd6) <br />-Rquired <br />Lf,tlq of Nolification <br />-l <br />cqtiry that thc lidoal rcgulatioro rcgarding mbctos rmoval rc not pplicable to this prcjcr. <br />-t <br />cqriry thd I havc red this applicstion dd statc thd the abovc bformation is corcct. I agr to @mply with all City md County <br />ordimcB dd Statc lrw rclating to building coNiructioD" dd hqcby adhorizc rcFe@tEtivc of this City md County to 6t6 upon thc <br />above motioncd propcny for <br />"",, 1 lzL l11 <br />APPROVALS DATE ID/SIG.COMMENTS <br />Appliances <br />I\Ietal 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 q-- J-l'l {Lczl <br />Vents <br />Toilet Room / Clothes Dryer <br />Residential Ranqe <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openinqs <br />lnstallation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Final Test <br />Meter Release - --'t <br />FINAL 54r /L(a|t ve-71# a / <br />Notes, Remarks, Etc. <br />MECHANICAL.INSPECTOR RECORD <br />I m cxmd ud6 S6tion <br />,"," -Ilzrolt? <br />,,,", 1lZ-Ll11 <br />",r", 1lz,b,l l7 <br />Da.vl4a <br />I <br />!