40134042 - Permit (3) - Laserfiche WebLink

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-M ECHANICAL.INSPECTOR RECORD APPROVALS DATE ID/SIG.COMMENTS OWNER BUILDER DEI,CARATION I haeby affrm unda pcnalty of pcrjury thd I m qmpt iom thc Contnctotr' LiccE [rw for thc following mmn (Sc.7031.5 Buine and Profsion Code): Any City or County which rcquira a pcrait to orutruct, alto, improvq ddholish or rtpair uy structrc. prior to ts isumcc. also rcquirB thc applicml for such Fmit to filc a signcd stdmat thsr hc or shc b licaBed plmet to thc prcvisioN of thc Contretor's Liccnsed [:w (Chaptc 9. Commcncing with Sction 7000 of Division 3 of thc BEilr* ud Prcfsions Codc) or thst hc q shr is cxcmpt thqefrom ud thc basis for thc allegcd umption. Any violrtion of Sdion 703 I .5 by oy applicotforapnritsubjslsthe applicmttoacivilpcnaltyofnotmorcthanfivehun&c{dollus($500). --1. as owner of the propcrty. or my employecxr with wages as their sole compensation. rvill do the rvork and the structure is not intended or offered for sale (Sec.7044. Business and hofessions Code: 'Ihe Contractor's License Law does not apply to an owner of the property who builds or improve thereon. and rvho docs such w'ort himself or herself or through his or hcr oun employees. provided that such improvonents are not intended or offcrod for sah. lf. horvsr/er. the building or funprovemâ‚¬nt is sold within one )Ear of cornpletion. the Orvner Builder will have the hrden of proving that he or she did not build or funprove the pnopety for the purpose of sale). -1. as owner of the property. am exclusively contracting u'ith licensed conlracton to construcl the project (Sec. 7044. Business and Profrssion Code: The Contractor's License Larv does not apply to an orvner of propcrty rvho builds or improves thereon. and rvho contracts fcrr such projects rvith a Contracto(s) licensed pursuant to the Contractor's License Law). _l am exempt under I].for this Dlt('t,A RA't'tON I hereby affirm under ;rnalty of perjury one of the follorving declarations: ,---l have and rvill maintain a Certilicate of Consent to Self-lnsure flrrr s'orkers' cornpensation. as provided for by Section 3700 of the l.abor Code. for the perfonnance of the rvork for s'hich the pernrit is issued. --l have and rvill maintain s'orkers' compensation insurance. as reauired by SEction -1700 of the Labor ('ode. for the performance of the w'ork for rvhich this permit is issued. My s'orkers' compensation insurance carrier and gnlicy number are: l'oliq'1 Nrrntbcr: l:rPirt's: -l cerri& that in the performance of the rvork for rvhich this perrnit is issued. I shall not employ any person in any manner so as to becorne subject lo the rvorkâ‚¬rs' compensalion larvs of California. and agreâ‚¬ that if I should become subject to the workers' compensation provisions of Section 3700 of the l.abor Code. I shall. forthrvilh cornply with those provisions.. WARNING: Failure to secure workers' compensation coverage is unlarvful. and shall subject an onployer to oiminal penalties and civil fines up to one hundred thousand dollars ($l to the compensation. darnages as provid$ for the Section -1076 of Labor Code. interest and attorney's â‚¬ I hereby affrrm under penalty of perjury that I arn licensed provision of Chapter 9 (commencing rvith Section 7000) of Division 3 of the Business and Professions Code. and my license is in full force and effect. I icettsc ('litss: Liccrrsc Nrrrrrttcr: W I hacby aflm undo Fulty of pcrjury th.t thft is I mnstruction kading agocy for thc psfomcc of thc mrk for which this Fmit b isucd (Sc. 3097. Civ. C.). l.cttrlcl 's N:trttt': l-ender's Address: APPI,ICAN'I' DE(:T,ARATION I h'r'elry alfinn unclcr penaltl' of periurl one of tlre frrllos'ing declarations: l)errrolitiorr Perrnits-Asbc'stos Notificatiorr Federal Regulations ('l'itle 40. Par16) _Rer;uired l.elter of Notification -l ccrtify that the federal regulations regarding asbcstos removal are not applicable to lhis project. -_l certify lhat I have read this application and state that the above rvith all City and County and County to carter ugnn theordinances and State Larvs relating to building above rnentioned property for Applicant or Agent Pennitee name r)are: ryn/? Appliances Metal Fire Place Evaporative Cooler Furnace Compressor Misc. Equipment Duct Work Pre-lnsulation lnsulation Smoke Detectors lnstalled Rough Ductwork Vents Toilet Room / Clothes Dryer Residential Range Other Hood Type I Hood Type ll Hood Grease Duct Fire Damper Openings lnstallation F.D. Drop Test Above Hard Lid Above T-Bar Rough Mech.1Z-cQl I Final Test Meter Release t I h FINAL ,r)t\\no DfrWlor'rrl Notes, Remarks, Etc.Ir l)nte: ('orrlrnclrlr: /2y'7-/(I aa