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MECHANICAL-INSPECTOR RECORD <br />APPROVALS DATE !D/SIG.COMMENTS OWNER BUILDER DELCARATION <br />I hcrcby affum undcr pnalty of pcrjury thal I m erempt from thc Contruclom' Lbcns Law for the following rcrsn (Ss.7031.5 <br />Busincss and Prcfession Code): Any City or County whkh rcquircs a fsmit to @nstrucl. allq. impmvc. demlish or rcl,air rny <br />structurc. prirr to its issu!rce. also requircs thc applicant for such Jrrmit to filc I siSrtd ststcmnt thlt lE or slE is liensd puN.nt <br />to the pmvisions of thc Contretor's Licensd lrw (Chapter 9, Comrcrcing with Setion 7000 of Division 3 of lhc Business ond <br />PrcfcssionsCodc)orthathcorsheiscxcmptthercfromsndtheb6sisforthcalhgcdexcmption. AnyviolstionofStrtionT03l,5byany <br />rpplicsnt for a lf,rmit subjats thc rpplicani to I civil penalty of not mrc thsn five hundrcd dollus ($5fi)). <br />-1. <br />as owner of the or my cmployces i with wsges as thcir sole compensation. willdo thc work ard the structure is not <br />and hofcssions Codc: The Contractor's Liccnse Law does not spply to an owner ofBusincss <br />the proJrcrty who builds or funprovcr thereon. and who does such work himsclf or herself or through his or her own cmployees. <br />provided that such improvenrnts are not interded or offered for sale. lf. howevcr. the building or inprorrerEnl is sold within one ytar <br />of conqrhtion. the Owner Builder will have the burdcn of proving that he or shc did not build or inqrrove the proprty for thc purpsc of <br />sah). <br />-1. <br />as owncr of the pro;rcrty. am cxclusivcly contracting with licensed contraclors lo construct lhe proict (Scc. 7W. Busincss <br />and Profe.ssion Code: Thc Contractor's License Law does not apply to an owncr of propcrly who builds or improves thcreon. <br />and who contracts for such proicts with a Contracto(s) licensed pursuant lo lhe Contractor's Liccnsc law). <br />-l <br />am cxcnrpt undcr B. & P.C. for this rcason. <br />f l.rl a.J lu.nor' <br />WORKERS' COMPENSATION <br />DECL^ RATION <br />I hcrcby affirm undcr penalty of perjury onc of the following dcclaralions: <br />-l <br />have and will maintain a Certifrcate of Conscnt to Self-lnsurc for workcrs' cnmSrcnsalion. as provided for by Scction 3700 of thc <br />Labor Code. for the pcrformance of the work for which the permit ls issued. <br />_l havc and <br />thc work for\ <br />will rnaintnin compcnsation insurancc. as hy Section 37il) of the l-abor Codc. for the performancc of <br />rcarrier arf nolicf numhr arc:issucd. <br />I 0t <br />Policy <br />-l <br />certify that in thc performance of thc work for which this pcrmit is issucd. I shall not employ any person in any manncr <br />so as to bccomc subjcct to thc workers'compensation laws of California. and agrcc that if I should bccorne subjcct to the <br />workers' comgrcnsation provisions of Scction 3700 of the Labor Codc. I shall. forthwith comply with thosc provisions.. <br />a <br />WARNING: Failure to liccure workcrs' compcnsation coveragc an cmploycr to crintinal pcnaltics und <br />i<ln. danugcs as providcd for thc <br />Scction 3076 of thc latnr Codc. intercst and attorncy's <br />I hereby alfirm undcr pcnalty of pcrjury that I am licenscd under pmvision of Chaptcr 9 (commencing with Scction 70m) of Division 3 <br />of thc Business and Profcssions Codc. and my license is in fuU.forcc and cffcct. <br />t00[-iccnsc Nurnhcr: <br />W <br />I hmby sfftrm undcr penrlty of pcrjury thst tJs! is 8 onstructirn lcnding sgcEy for lhe pcrfom of ]hc work for which lhis Frmil is <br />issued (Ss. 3097. Civ. C.). <br />lrndcr's Nanrc: <br />lrndcr's Addrcss: <br />"''.ANT "rcLARI hcrcby allrnn undcr penalty of pcrjury onc of thc lbllowing dccluralions: <br />Dcmolit ion Pcrnrits- Asbcstos Notifical ion Fcdcral Regulat ions ('I'it lc 40. Part6) <br />-Requ <br />ircd Letter of Not ification <br />_l ccrtify that thc t'cdcralregulalions rcgarding asbcslos rcrnovalare nol applicahlc to this projcct. <br />_l ccrtify thal I have rcad this abovc information is correct. I agrcrc to comply with all City and County <br />orrlirranccs :rrrtl Slalc L-aws rcprcsentalivcs of this City and County to <br />lhlvc nrcnliorrcd propcrty l'or <br />Applicanl or Agcnt 1 <br />I'cnrritcc rrurrrc ( <br />Io <br />I <br />0 <br />,J8 upon 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 />Residentia! Range <br />Other <br />Hood <br />Type I Hood <br />Type ll Hood <br />Grease Duct <br />Fire Damper <br />Openinqs <br />Installation <br />F.D. Drop Test <br />Above Hard Lid <br />Above T-Bar <br />Rough Mech. <br />Fina! Test <br />Meter Release <br />FINAL llqr,D /l/ C c,vr'eia_s vzy <br />Notes, Remarks, Etc. <br />Expires: <br />-Date: <br />fr,